Role Overview
This position focuses on the accurate review and processing of stop loss claims, ensuring alignment with contractual obligations and policy requirements. The analyst plays a key role in upholding compliance, supporting financial accountability, and contributing to a healthcare experience centered on individuals.
Key Responsibilities
- Apply contract terms correctly to determine claim eligibility and identify incomplete or non-compliant submissions
- Interpret policy language and procedural guidelines, referencing documentation as needed to support decisions
- Determine appropriate claim outcomes, including payment, denial, or requests for additional information
- Lead efforts to monitor, evaluate, and report aggregate claims data
- Conduct on-site and remote audits of aggregate claims based on established financial thresholds
- Generate audit reports for clients as required
- Maintain an organized workflow of claims, adhering to best practices and processing standards
- Identify and implement improvements in tracking and handling claims
- Document all claim activity thoroughly to support team collaboration and audit readiness
- Investigate claims in detail, requesting supporting records when necessary to ensure accurate and timely resolution
Required Qualifications
- High School Diploma or equivalent
- Minimum of five years of professional experience in claims processing, or a combination of education and relevant experience
- Ability to consult legal and clinical resources to interpret complex terminology and support claim determinations
- Solid understanding of policy and contract provisions, including deductible aggregation, eligibility rules, and claim lasering
- Advanced proficiency in claim reserving and settlement practices
- Strong communication skills for interacting with internal teams and external stakeholders
- Familiarity with medical terminology and ICD-10/CPT coding standards
Preferred Qualifications
- Experience using AI tools to support decision-making and improve efficiency in professional environments
Work Environment
This role operates remotely for candidates based in Oregon, Idaho, or Utah. A reliable wired internet connection is required, with minimum upload speed of 5Mb and download speed of 10Mb. Work-from-home flexibility is supported across most positions.
Compensation and Benefits
The expected hiring range for this position is $68,900 to $93,150 annually, with a full salary range from $64,000 to $106,000. Employees are eligible for a 6.25% bonus target based on performance. Additional benefits include comprehensive medical, dental, and vision coverage for employees and eligible dependents, mental health support, and an employer contribution to a health savings account.
Generous paid time off and 10 company-paid holidays are provided, along with a market-leading retirement plan featuring company match on 401(k) contributions and potential discretionary contributions. Eligible employees may receive up to 12 weeks of paid parental leave after one year of service. Wellness programs, employee assistance resources, and commute benefits are also available.
