Auditor, Sr Stoploss Claim

BlueCross BlueShield of South Carolina•Pace, VT

6d•Hybrid

About The Position

Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Description Position Purpose: Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Logistics: PACE Underwriters – one of BlueCross BlueShield's South Carolina subsidiary companies. Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-4:30pm CST and will be fully remote or hybrid if based near our Dallas office. What You’ll Do: Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier. Recognize cost mitigation opportunities. Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits. Initiate claims investigations and vendor referrals. Interpret plan language, and identify experimental services and subrogation opportunities. Identify need for follow-up on pended claims and resolution. Communicate effectively with carriers, vendors, and management. Provide full claims service to both phone and written inquiries. Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history. Develop new and review old stop loss claim forms. Assist with internal auditing of claims auditors, and training of claims auditors.

Requirements

Associate's
6 years of managed care or reinsurance claims experience.

Nice To Haves

Analyzes laws, regulations and contract language.
Evaluates issues and develops recommendations.
Handles confidential and sensitive information.
Investigates assigned claims.
Proposes claims adjustments and refunds.
Works claims caseloads.
Aggregate claims experience.

Responsibilities

Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
Recognize cost mitigation opportunities.
Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
Initiate claims investigations and vendor referrals.
Interpret plan language, and identify experimental services and subrogation opportunities.
Identify need for follow-up on pended claims and resolution.
Communicate effectively with carriers, vendors, and management.
Provide full claims service to both phone and written inquiries.
Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
Develop new and review old stop loss claim forms.
Assist with internal auditing of claims auditors, and training of claims auditors.