At Great American Insurance Group, we combine the collaborative, idea-driven culture of a smaller company with the resources and expertise of a large enterprise. We are seeking a Senior Specific Claim Auditor to adjudicate high-dollar and complex medical stop-loss claims, verifying eligibility, analyzing for cost-containment, and ensuring strict compliance with regulations and internal policies.
What You'll Do
- Receive, log, and validate incoming stop-loss claims and related documentation, requesting missing information as needed.
- Verify eligibility, plan benefits, and stop-loss policy provisions, entering claim details accurately into the system of record.
- Maintain electronic claim files for audit and compliance purposes.
- Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims.
- Identify cost-containment opportunities and implement strategies with carriers and TPAs.
- Document audit findings and maintain accurate records.
- Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams, providing clear updates on claim status.
- Offer guidance to clients on claims procedures and coverage issues.
- Ensure adherence to regulatory requirements, internal controls, and fraud prevention policies.
- Stay current on industry trends, regulations, and best practices; participate in special projects and process improvement initiatives.
- Identify opportunities to streamline claim intake and processing workflows.
- Train and mentor junior claims processors on best practices.
What We're Looking For
- Minimum 10 years in medical stop-loss claims processing or related health insurance claims roles.
- Proficiency in medical coding (ICD-10, CPT, HCPCS).
- Advanced Excel skills.
- Expertise with claims processing systems.
- Strong understanding of stop-loss insurance, plan documents, and claims handling practices.
- Exceptional analytical ability, attention to detail, and strong written and verbal communication skills.
Benefits & Compensation
- Compensation range: $80,000.00 - $106,000.00
- Medical, dental, and vision coverage
- Wellness plans
- Parental leave
- Adoption assistance
- Tuition reimbursement
- Paid Time Off and paid holidays
- 401(k) plan with company match
- Employee stock purchase plan
- Commuter benefits
We value the benefits derived when people with different backgrounds and experiences work together. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best.
