Seasonal Senior Claims Auditor/Consultant

Job Description:

• Manage and adjudicate a portfolio of complex Employer Stop Loss claims within established authority levels and in accordance with policy and contract provisions.
• Review and interpret Stop Loss policies, certificates, plan documents, eligibility provisions, deductibles, exclusions, reimbursement provisions, and other contractual terms to determine claim eligibility and reimbursement.
• Conduct comprehensive reviews of high-dollar, complex, and unusual claims, including significant medical expenses, transplant, oncology, catastrophic conditions, specialty drugs, and other high-cost services.
• Analyze claims data, medical records, eligibility information, provider documentation, invoices, and supporting documentation to validate claim accuracy and reimbursement.
• Review claims for appropriate adjudication, including eligibility, deductibles, exclusions, benefits, payment calculations, and application of policy terms.
• Manage large-loss claims and provide reporting, analysis, recommendations, and escalation to the Vice President of Claims and other stakeholders.
• Review and recommend reserves for large and complex claims based on available information, anticipated claim liability, policy provisions, and reserving guidelines.
• Monitor large claims throughout their lifecycle and update reserves, claim estimates, and management reports.
• Conduct pre- and post-payment claim audits to identify payment inaccuracies, processing errors, documentation deficiencies, and opportunities for recovery or correction.
• Identify trends, recurring errors, system issues, and process deficiencies affecting claim accuracy or financial performance and recommend corrective action.
• Work with TPAs and external claims administrators to resolve complex claims issues, validate claim information, and ensure contractual and administrative compliance.
• Manage inquiries and escalated claim matters from brokers, TPAs, plan sponsors, Underwriting, reinsurers, and other stakeholders.

Requirements:

• Bachelor's degree required.
• Minimum of seven (7) years of progressive experience in claims, with significant experience in Employer Stop Loss, medical claims, health benefits, or a related insurance environment.
• Demonstrated experience handling complex and high-dollar medical claims.
• Experience with claims auditing, adjudication, payment review, and claims analysis.
• Experience interpreting insurance contracts, plan documents, and claims provisions.
• Experience managing large-loss claims and making reserve recommendations.

Benefits:

• Health Benefits: Medical/Rx, Dental, Vision, Life Insurance, Disability Insurance
• Financial Benefits: ESPP; 401k; Student Loan Assistance; Tuition Reimbursement
• Free Mental Health & Enhanced Advocacy Services
• Paid Time Off
• Holidays
• Preferred Partner Discounts