Specific Stop Loss Claims Auditor
Core
Analyze and validate Specific Stop Loss claims for MGU and Carrier clients, ensuring expenses align with stop loss policies and plan descriptions.
Role type
Specific Stop Loss Claims Auditor
Builds
Claims audit reports and validation for healthcare risk management clients
Domain
Healthcare insurance / Reinsurance
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Excel proficiency (formulas, sorting, PIVOT Tables), claims adjudication, stop loss policy interpretation, deductible/coinsurance calculation, industry repricing methodologies (PPO, Wrap Networks, Reference Based Pricing), Microsoft Office
Preferred skills
Managed care audit experience, process improvement initiatives
Responsibilities
Analyze Specific Stop Loss claims, isolate claim-specific data, validate eligible expenses, apply deductibles and coinsurances, provide customer service to MGU partners and TPAs, follow up on pended claims, contribute to new process implementations
Seniority
Mid-level, hands-on IC