Stop Loss & Health Claim Analyst
Core
Reviewing health claims, interpreting contracts, and determining reimbursement or denial for Stop Loss claims to manage financial risk.
Role type
Stop Loss & Health Claim Analyst
Builds
Medical stop-loss insurance claims decisions and reimbursement disbursements
Domain
Health insurance / Claims administration
Required skills
Stop Loss claims processing, contract interpretation, HIPAA compliance, Affordable Care Act knowledge, medical record analysis, claim eligibility determination, cost containment planning, Microsoft Office proficiency
Preferred skills
First dollar medical claims experience, negotiation, underwriting solutions, industry claim practices awareness
Responsibilities
Determine claim eligibility by applying contractual provisions to medical facts; Prepare written rationale for claim decisions based on contract and plan specifications; 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