Examiner - Stop Loss

Symetra • ,

9d • $25 - $41 • Hybrid

About The Position

Audit Individual Excess Loss claim submissions by analyzing excess loss policy provisions, employer plan document provisions, administrative agreements, and cost containment vendor agreements to ensure accurate claim reimbursements payable to the policyholder. Review potential claim notices and submissions for cost containment options and refer to Medical Risk Consultants or Cost Containment specialists.

Requirements

• High school diploma or equivalent work experience, college degree a plus.
• 1-3 years of cumulative, relevant experience
• Medical procedure terminology required
• Proficiency with Excel

Nice To Haves

• Audit and bill review experience is a plus
• Aggregate experience is a plus

Responsibilities

• Review and decide on reimbursement of excess loss claims following the terms outlined in the Policyholder's Plan Document and Excess Loss Policy.
• Process claim reimbursements within established turnaround time targets.
• Sustain more than 99% accuracy in claim handling and financial correctness, including necessary documentation of relevant claimant, plan, and policy details.
• Maintain current pending claims with consistent follow-up, documentation, and resolution or closure within defined timeframes.
• Interact with TPA contacts and other resources to clearly communicate information needed to make reimbursement decisions.
• Provide timely turnaround when requested information is received for reimbursement or denial.
• Review advance notices of potential claims to identify and refer cases encouraged to become excess loss claims, needing MRC attention for renewal information or cost containment.
• Alert MRCs, RGMs, and Underwriters of possible catastrophic claims risk as well as unusual and complex claim issues.
• Interact with internal and external customers responding to inquiries, handling appeals, facilitating claim resolutions, and providing and acquiring education in industry claim trends and cost containment solutions.
• Undertake special projects as identified by management.

Benefits

• Flexible full-time or hybrid telecommuting arrangements.
• 401(k) plan with immediate vesting and company matching up to 6%.
• Paid time away including vacation and sick time, flex days and ten paid holidays.
• Company matching for community contributions.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED