Claims Analyst, Health and Risk Solutions
Core
Reviewing claims, interpreting contracts, dispersing reimbursement, and managing financial risk for Stop Loss claims in the health benefits sector.
Role type
Claims Analyst (Health & Risk Solutions)
Builds
Stop Loss claim determinations and reimbursement decisions for employer/government benefit plans
Domain
Health insurance / Employee benefits
Deliverable
Dashboards & analysis
Required skills
Contract interpretation, claims adjudication, HIPAA compliance, regulatory knowledge, case management, cost containment planning, medical record analysis
Preferred skills
Healthcare industry knowledge, negotiation, solutions-based underwriting, Microsoft Office proficiency
Responsibilities
Determine claim eligibility based on contractual provisions and medical facts; prepare written rationale for claim decisions; maintain claim block metrics; coordinate with clinical and investigative resources; implement cost containment initiatives
Seniority
Individual Contributor
