Claim Analyst III Stop Loss

Medica•Minnetonka, MN

57d•Hybrid

About The Position

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for. We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued. Medica's Claim Analyst III (Stop Loss) serves as a subject matter expert responsible for reviewing, analyzing, and processing stop-loss claims to ensure accuracy and compliance with contractual guidelines. This senior-level professional builds and maintains operational relationships with internal and external stakeholders, supports process improvements, and provides expertise in claims adjudication and reconciliation. Performs other duties as assigned.

Requirements

Bachelor's degree or equivalent experience in related field
5 years of work experience beyond degree

Nice To Haves

Strong analytical, organizational, and communication skills
High attention to detail; ability to manage multiple priorities under tight deadlines
Proficiency in Microsoft applications and claims systems
Knowledge of ICD-10, CPT/HCPCS coding, and coordination-of-benefits principles

Responsibilities

Review and Analyze Claims: Examine stop-loss claims to confirm eligibility, contract terms, and policy limits. Ensure claims are processed accurately and meet production standards
Claims Verification: Verify that all underlying claims are paid appropriately according to standard operating procedures
Claims Tracking and Reconciliation: Track claim submissions, monitor status, and reconcile medical records and correspondence. Collaborate with internal teams (Claims, Utilization Management, Client Services) to resolve eligibility and coordination-of-benefits issues
Process Improvement: Identify opportunities to enhance accuracy and turnaround time (TAT) for stop-loss claims. Support management with ad hoc analysis and reporting related to claims adjudication and stop-loss
Stakeholder Engagement: Build and strengthen relationships with stakeholders through effective problem resolution and communication