Responsibilities
- Receive and verify incoming stop-loss claims, logging them and requesting any missing documentation as necessary.
- Confirm eligibility, coverage terms, and policy details while accurately inputting claim data into the system.
- Keep electronic claim records organized and accessible for audits and regulatory compliance.
- Evaluate and process complex, high-cost medical stop-loss claims with precision.
- Detect opportunities to reduce costs and apply strategies in coordination with insurance carriers and third-party administrators.
- Record findings from audits and ensure all claim-related data is accurately maintained in the system.
- Communicate clearly and promptly with TPAs, brokers, policyholders, and internal departments regarding claim status and requirements.
- Advise clients on claim procedures and clarify coverage-related questions.
- Ensure all activities comply with regulations, internal controls, and anti-fraud policies.
- Stay informed about changes in healthcare regulations, industry standards, and best practices; contribute to reporting and process enhancements.
- Find ways to improve the efficiency of claim intake and processing workflows.
- Provide training and support to junior claims staff on effective practices.
- Carry out additional tasks as required by management.
Benefits
- Comprehensive medical, dental, and vision insurance plans
- Wellness program offerings
- Paid parental leave
- Financial assistance for adoption
- Reimbursement for qualifying tuition expenses
- Generous paid time off and holiday leave
- 401(k) retirement plan with employer matching
- Opportunity to purchase company stock through an employee plan
- Commuter benefits for eligible employees
Compensation
Compensation varies by role, level, and location and is influenced by skills, experience, and business needs.
Work Arrangement
Remote (City/Region)
Excludes seasonal employees and interns.
