Stop Loss Claims Specialist

Job Type:

Essential Duties and Responsibilities

  • Pursue the final Aggregate Claim documentation from third-party administrators, in support of the Policy End Aggregate Reconciliation Process. Will be responsible for reviewing final Aggregate Claim Reports and other related documentation to determine if refunds are due from the Policyholders, along with assisting in the pursuit of subrogated matters and assorted types of overpaid claim scenarios, as applicable.
  • Responsible for reviewing and adjudicating Monthly Aggregate Accommodation Re-quests, taking into consideration all applicable Stop Loss Policy Provisions, Plan Document Pro-visions, and internal claims processing protocols, within assigned authority limit.
  • Responsible for the following: Consult with Claims Management or other departments (e.g., Underwriting, Administration, etc.) to handle/resolve complex claims and/or potential claim issues.
  • If claim exceeds assigned authority, responsible for sending claim to immediate Claims Supervisor/Manager for review and authorization to proceed claim exceeds company’s authori-ty, will also be responsible for sending claim to Stop Loss Carrier for review and authorization to proceed.
  • Respond to carrier’s request for additional information/documentation, as needed. If claim benefits/payments are applicable, responsible for compiling necessary documentation in preparation for internal claim payment submission process, and responsible for submitting payment requests to Claims Management and Accounting/Finance representatives.
  • Update claim system and internal claim files/folders accordingly. Once the claim is completed/approved, send the Explanation of Benefits Statement (“EOB”) and/or Declination Notice, as applicable, to the TPA and Policyholder.
  • Perform Claim Intake Process, as needed, which entails setting up a new claim in the system, creating a new claim folder in our shared file system, and uploading the claim docu-mentation in the new claim folder.
  • Regularly follow up with Third Party Administrators (“TPAs”) and Policyholders to check status of our requests for information/documentation in pended claim scenarios.
    Qualifications for the Stop Loss Claims Specialist include:
  • Minimum of 5 years of experience with medical claims processing and adjudication.
  • Experience with third party administration, self-funding, stop loss claims, excess loss claims, and/or reinsurance is preferred. Aggregate claim experience is also preferred.
  • Must have knowledge of CPT, ICD-10, and HCPCS codes, along with knowledge of medi-cal claim practices. Additional knowledge of medical billing and coding practices preferred.
  • Strong analytical skills/abilities, along with having keen critical decision-making and problem-solving skills, are a must.
  • Highly proficient in Microsoft Office applications, especially Outlook, Excel, and Word.
  • Excellent verbal and written communication skills, along with sound organizational skills, and effective customer service abilities are necessary.
  • Must have the ability to work effectively on a team, as well as work well independently.
  • Must be able to work in a fast-paced environment and maintain acceptable productivity, while maintaining a high level of quality.

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