Claims Examiner-Stop Loss Coord Sr CCH
About The Position
The Senior Claims Examiner and Stop Loss Coordinator is responsible for reviewing and processing complex professional and hospital claims for Community Care Health (CCH) in-network and out-of-network providers. This role will review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorization, and process them for payment. Tracks potential and existing stop loss members, timely filing of all stop loss claims with the carrier, follow-up with the carrier regarding outstanding recoveries, and reporting. Provides overall assurance that CCH is in compliance with the stop loss policy. Trains new or existing staff on any claims system enhancements.
Requirements
- High School Diploma, High School Equivalency (HSE) or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
- 4 years of medical claims processing/adjudication experience required
- Experience working with claims system/applications and troubleshooting
Nice To Haves
- Experience with self-funded, tribal, and non-tribal insurance plans.
- Experience with Blue Shield (due to current integration).
- Medicare Experience (department heavily utilizes CMS guidelines in their processing, so Medicare knowledge overlaps by 80% to 90%).
- Associate's Degree preferred
- TriZetto/QNXT system knowledge preferred
Responsibilities
- Reviewing and processing complex professional and hospital claims for Community Care Health (CCH) in-network and out-of-network providers.
- Reviewing, analyzing, and researching healthcare claims to identify discrepancies, verify pricing, confirm prior authorization, and process them for payment.
- Tracking potential and existing stop loss members, timely filing of all stop loss claims with the carrier, follow-up with the carrier regarding outstanding recoveries, and reporting.
- Providing overall assurance that CCH is in compliance with the stop loss policy.
- Training new or existing staff on any claims system enhancements.
Benefits
- Free Continuing Education and certification
- Tuition reimbursement, education programs and scholarships
- Vacation time starts building on Day 1, and builds with your seniority
- Free money toward retirement with a 403(b) and matching contributions
- Great food options with on-demand ordering
- Free parking and electric charging
- Commitment to diversity and inclusion
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
