Stop Loss Claims Auditor

Imagine360 is seeking a Stop Loss Claims Auditor to join the team! This position is part of the Stop Loss Department and supports multiple functions within the department including, but not limited to, claims examination, auditing, reviewing, and processing. The person in this position must demonstrate a proficient knowledge of all Stop Loss processes and procedures. Position Location: 100% remote Responsibilities Demonstrate above average technical knowledge of all aspects of the stop loss process, specifically the claims review process Monitor claims inbox and respond, in a timely fashion, to all incoming claims. Compile and review all claims information including employer health plans, stop loss insurance contracts, provider documentation, and all other claim evidence. Audit submitted claims for sufficient data, verifying that benefits are paid correctly and in accordance with appropriate plans and policies. Prepare written rationale of claim decisions based on review of appropriate evidence, contracts, etc. Set claim reserves and adjust as needed. Enter appropriate stop loss claims and violations into designated database. Identify, research, and resolve stop loss carrier questions or issues. Facilitate advance funding with Finance Department. Comply with reporting and documentation requirements. Coordinate tracking and reporting of stop loss violations. Manage large case notification process. Manage various reporting requirements. Notify claims team and/or underwriting staff of newly disclosed claimants or extremely high‑risk claimants after review of incoming precertification’s and reports. Customer Service Receive and respond in a timely and accurate manner, both orally and in writing, to customer inquiries regarding claims and plan documents. Act supportively and empathetically to internal and external customers. Appropriately escalates difficult issues up the chain of command. Model and provide an environment that supports Imagine360 core values to encourage continuous learning, personal development and accountability. Actively support company and department initiatives, supervisors and other team members. Quality Assurance Actively participate in team/department meetings and training initiatives. Perform self‑quality monitoring in order to develop and execute plans to meet established goals. Provide ongoing feedback to help optimize quality performance. Collaborate with staff and cross‑departmentally to improve or streamline procedures. Required Experience / Education Associate or Bachelor's Degree or combination of experience and education 3-5 years of processing first dollar medical claims Processing Stop Loss Claims experience Prior experience in self‑insured plan management Prior experience in Stop Loss Claims and Stop Loss industry Skills and Abilities Strong communication (telephonic, oral, and written), interpersonal relationship, analytical and problem‑solving skills as well as detail oriented. Working knowledge of computers and software including but not limited to Microsoft Office products. Demonstrated ability to work independently, prioritize workloads, multi‑task and manage priorities in order to meet deadlines. Knowledge of legal risks and regulatory/statutory guidelines of HIPAA, privacy, Patient Protection and Affordable Care Act, etc. Knowledge of Medical Terminology, CPT (Current Procedural Terminology), and International Classifications of Diseases (ICD‑10). Benefits Multiple Health plan options Company paid employee premiums for disability and life insurance Parental Leave Policy 20 days PTO to start / 10 Paid Holidays Tuition reimbursement 401k Company contribution Company paid Short & Long term Disability plus Life Insurance Professional development initiatives / continuous learning opportunities Opportunities to participate in and support the company's diversity and inclusion initiatives Imagine360 is a health plan solution company that combines 50+ years of self‑funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one‑size‑fits‑none PPO insurance problems with powerful, customized, member‑focused solutions. Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. #J-18808-Ljbffr Imagine360, LLC