Claims Examiner I

Beyond Risk Management Inc•Beverly, MA

2d•Onsite

About The Position

Beyond Health Partners, LLC, a Beyond Risk affiliate company, is looking for a motivated Claims Examiner I to join their growing stop loss claims team. This role is ideal for individuals with early claims experience who are detail-oriented, enjoy problem-solving, and are eager to learn the intricacies of medical stop loss insurance. The position involves reviewing claim submissions, verifying documentation, collaborating with internal and external partners, and ensuring timely and accurate claim reimbursements. Successful candidates will work alongside experienced claims professionals to develop technical expertise, enhance judgment, and thrive in a collaborative team setting.

Requirements

Bachelor’s degree in a related field or equivalent work experience.
At least two years of property, casualty, medical, or other claims-related experience preferred.
Strong attention to detail and an interest in reviewing documentation, data, and policy information accurately.
Curiosity and willingness to learn medical stop loss insurance, plan documents, reimbursement processes, and case reserve concepts.
Clear written and verbal communication skills with the ability to interact professionally with internal and external partners.
Comfort using claims management systems, Microsoft Office Suite, and other business applications.
Ability to work both independently and as part of a team in a deadline-driven environment.
Willingness to obtain a MA A&H Producer license within the first three months of employment.
Must be local to the Beverly, Massachusetts area.

Responsibilities

Process employer stop loss insurance claims for multiple carrier partners, adhering to established carrier procedures, company guidelines, and regulatory requirements.
Review claim submissions for completeness, accuracy, eligibility, coverage, and alignment with the plan document and stop loss policy to support accurate reimbursement decisions.
Audit documentation, identify missing information, recognize potential cost containment opportunities, and request additional details as needed.
Professionally interact with TPAs, producers, healthcare providers, vendors, carrier partners, and internal team members to facilitate claim progression.
Maintain organized records of claim activity, correspondence, payments, case reserves, decisions, and resolutions in accordance with company standards.
Assist in setting and monitoring case reserves for assigned claimants, including researching medical conditions and treatment plans, and documenting reserve rationale with management support.
Perform quality checks to ensure accurate and consistent claim processing.
Contribute ideas for improving claim workflows, documentation, efficiency, and the overall claims experience.
Apply relevant policies, procedures, and regulatory guidelines, understanding how compliance contributes to strong claim outcomes.
Assist with logging new claim submissions, notifications, claims reporting, cross-training, high-volume periods, and special projects assigned by management.