Stop Loss & Health Claim Analyst
Core
Reviewing health claims, interpreting contracts, and determining reimbursement or denial for stop-loss insurance blocks.
Role type
Stop Loss & Health Claim Analyst
Builds
Medical stop-loss insurance coverage decisions
Domain
Health Insurance / Claims Administration
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Stop Loss claims processing, contract interpretation, medical record analysis, HIPAA compliance, Affordable Care Act knowledge, claim eligibility determination, cost containment planning
Preferred skills
Negotiation, solutions-based underwriting, industry claim practices awareness
Technologies
Microsoft Office suite
Responsibilities
Determine claim eligibility by applying contractual provisions to medical facts; Prepare written rationale for claim decisions; Maintain claim block production and quality metrics; Coordinate cost containment initiatives with clinical resources; Establish relationships with internal and external professional resources (medical, investigative, legal)
Seniority
Mid-level, hands-on IC