The Stop Loss Claims Analyst is responsible for adjudicating stop loss claims by applying policy and contract terms, ensuring compliance with laws and regulations, and supporting a person-focused healthcare experience. This role requires strong analytical skills, attention to detail, and collaboration within a dedicated team to ensure accurate and timely claim processing at Cambia Health.
What You'll Do
- Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims
- Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details
- Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information
- Lead the process to measure, track, and report all aggregate claims
- Audit all aggregate claims onsite and off-site when needed based on set dollar threshold
- Provide client audit reporting as needed
- Manage inventory of claims while ensuring best practices and claim standards are met
- Identify new opportunities to track and process claims more efficiently
- Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes
- Analyze and investigate all claims
- Request supplementary documentation as necessary to process or reprocess claims in a timely and accurate manner
What We're Looking For
- High School Diploma or GED
- 5 years of professional claims processing experience or equivalent combination of education and experience
- Knowledge of when to utilize legal and clinical resources to comprehend legal and medical terminology in order to make final determinations on whether to approve or further investigate a claim
- Possess strong knowledge of Policy and Contract terms, lasering, aggregating deductibles and eligibility to ensure correct processing of all eligible claim reimbursements
- Advanced knowledge of claim reserving and settlement
- Excellent communication skills for both external and internal customers
- Demonstrate understanding of medical terminology and ICD-10/CPT coding
Nice to Have
- Experience with AI tools and technologies to enhance productivity and decision-making in professional settings
Technical Stack
- AI tools and technologies
Benefits & Compensation
- Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits
- Annual employer contribution to a health savings account
- Generous paid time off varying by role and tenure
- 10 company-paid holidays
- Market-leading retirement plan including a company match on employee 401(k) contributions
- Potential discretionary contribution based on company performance (no vesting period)
- Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave)
- Award-winning wellness programs that reward you for participation
- Employee Assistance Fund for those in need
- Commute and parking benefits
- Work from home options for most of our roles
- Competitive base pay
- Market-leading 401(k) with a significant company match
- Bonus opportunities
The expected hiring range for a Stop Loss Claims Analyst is $68,900.00 - $93,150.00 depending on skills, experience, education, and training; relevant licensure / certifications; performance history; and work location. The current full salary range for this role is $64,000.00 to $106,000.00. Bonus target for this position is 6.25%.
Work Mode
Hybrid role with work locations in Oregon, Idaho, and Utah. Work from home options available; requires wired internet connection (not satellite or cellular) with minimum upload speed of 5Mb and download speed of 10Mb.
Team & Environment
- Purpose-driven
- Award-winning culture built on trust and innovation
- Caring and supportive colleagues
- Innovating toward sustainable, person-focused health care
- Compassion, empathy, and team spirit
- Diverse teams building cutting-edge solutions
- Commitment to helping employees succeed
- Community involvement through outreach programs
- Employee resource groups for connection and inclusion
We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
