Stop Loss Claims Analyst

Job Summary

Responsible for reviewing claims and ensuring proper documentation for Stop Loss claims, the full-time Stop Loss Claims Analyst will manage the eligibility determination process, apply contractual provisions, and maintain claim blocks while working remotely.

Key responsibilities

• Determine claim eligibility by applying contractual provisions to medical facts and specifications
• Maintain claim block and meet departmental production and quality metrics
• Prepare written rationale for claim decisions based on contractual provisions and medical record analysis

Required qualifications

• Three to five years of experience in processing first dollar medical claims or Stop Loss claims
• Knowledge of Stop Loss claims and the Stop Loss industry preferred
• Demonstrated success in negotiation and solutions-based underwriting
• Overall knowledge of the healthcare industry
• Proficiency in Microsoft Office suite