Senior Stop Loss Claims Analyst - HNAS

Job Summary

This role reviews, evaluates, and processes Stop Loss (Excess Risk and Reinsurance) claims in accordance with established turnaround and quality standards. The analyst builds positive client relationships, provides education, and analyzes client claim losses while following departmental claim procedures and maintaining accurate claim records.

• Process daily incoming Stop Loss claims including initial entry and subsequent claims as required.
• Evaluate claims submitted by TPAs and PBMs for compliance with policy provisions, regulatory guidelines, and industry standards.
• Monitor, review, and analyze complex potential claims with emphasis on controlling losses through effective managed care, including audit for duplicate charges and accurate payment requests.
• Determine whether to pend or adjudicate claims following organizational policies, finalize adjudications up to pre-determined dollar threshold, and complete pended claim letters for incomplete, invalid, or missing information.
• Identify potential discrepancies and involve the Special Investigation Unit as necessary, using findings to educate, streamline, and improve processes and documentation.
• Assist leadership with performing client performance evaluations to assess the accuracy of client reports and efficiency of claim operations.
• Approve claim payments on behalf of multiple clients and provide client counseling and support services, including revising and establishing procedures and ensuring client satisfaction.
• Maintain accurate claim records.
• Other duties as assigned or requested.

Required:

High School Diploma or GED.

Preferred:
Bachelor’s degree.

• Required:
  
  5 years of relevant, progressive experience in health insurance claims.
• Required:
  
  3 years of prior experience processing 1st dollar health insurance claims.
• Required:
  
  3 years of experience with medical terminology.
• Preferred: 3 years of experience in a Stop Loss Claims Analyst role.

• Ability to communicate concise, accurate information effectively.
• Organizational skills.
• Ability to manage time effectively.
• Ability to work independently.
• Problem solving and analytical skills.

Minimum $22.71, maximum $35.88.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on protected veteran status or disability status and all protected categories in accordance with applicable federal, state, and local law.

If you would like assistance completing the application process, please contact HR Services Online at HRServices.