About the Role
The role involves auditing complex medical claims to verify adherence to plan terms, identifying overpayments, and supporting clients through accurate financial reporting and resolution of disputed claims.
Responsibilities
- Examine stop loss insurance claims for correctness and policy compliance
- Identify discrepancies in claim processing and billing data
- Collaborate with third-party administrators and clients to resolve issues
- Validate claim reimbursements against contractual agreements
- Prepare detailed audit reports summarizing findings and recommendations
- Track and document claim adjustments and recoveries
- Ensure audit processes follow regulatory and internal standards
- Support client inquiries related to claim determinations
- Maintain accurate records of audit activities and outcomes
- Assist in improving audit methodologies and tools
Nice to Have
- Direct experience auditing stop loss claims
- Knowledge of ERISA and healthcare compliance regulations
- Background working with third-party administrators (TPAs)
- Experience using claims auditing software platforms
Compensation
Competitive salary and benefits package offered
Work Arrangement
Hybrid work model with flexibility based on location and role needs
Team
Part of a specialized risk management team focused on claims accuracy and financial oversight
Why This Role Matters
- Accurate claims auditing protects organizations from financial loss and ensures fairness in self-insured health plan operations
- This role directly contributes to client trust and long-term risk management success
Growth Opportunities
- Opportunities to take on complex cases and mentor junior staff
- Potential to influence process improvements and system enhancements
Not available for this position
