Seasonal Senior Claims Auditor/Consultant

Brown & Brown Insurance•Remote - Pennsylvania, PA

About The Position

One80 Intermediaries is seeking a Seasonal Senior Claims Auditor/Consultant to join their growing team. The Senior Claims Consultant is responsible for the effective management, review, adjudication, and resolution of complex Employer Stop Loss claims within established authority levels. This position provides senior-level technical expertise in claims analysis, contract interpretation, claim payment accuracy, eligibility, large-loss management, reserving, and audit oversight. The Senior Claims Consultant works closely with the Vice President of Claims, claims team, Underwriting, brokers, Third-Party Administrators (TPAs), medical vendors, carriers, reinsurers, and other internal and external stakeholders to ensure claims are processed accurately, efficiently, and in accordance with policy terms, contractual requirements, regulatory standards, and company procedures.

Requirements

Bachelor's degree required.
Minimum of seven (7) years of progressive experience in claims, with significant experience in Employer Stop Loss, medical claims, health benefits, or a related insurance environment.
Demonstrated experience handling complex and high-dollar medical claims.
Experience with claims auditing, adjudication, payment review, and claims analysis.
Experience interpreting insurance contracts, plan documents, and claims provisions.
Experience managing large-loss claims and making reserve recommendations.

Responsibilities

Manage and adjudicate a portfolio of complex Employer Stop Loss claims within established authority levels and in accordance with policy and contract provisions.
Review and interpret Stop Loss policies, certificates, plan documents, eligibility provisions, deductibles, exclusions, reimbursement provisions, and other applicable contractual terms to determine claim eligibility and reimbursement.
Conduct comprehensive reviews of high-dollar, complex, and unusual claims, including claims involving significant medical expenses, transplant, oncology, catastrophic conditions, specialty drugs, and other high-cost services.
Analyze claims data, medical records, eligibility information, provider documentation, invoices, and other supporting documentation to validate claim accuracy and reimbursement.
Review claims for appropriate adjudication, including eligibility, deductibles, exclusions, benefits, payment calculations, and application of policy terms.
Manage large-loss claims and provide timely reporting, analysis, recommendations, and escalation to the Vice President of Claims and other appropriate stakeholders.
Review and recommend appropriate reserves for large and complex claims based on available information, anticipated claim liability, policy provisions, and established reserving guidelines.
Monitor large claims throughout their lifecycle and update reserves, claim estimates, and management reports as new information becomes available as requested by VP of Claims.
Conduct pre- and post-payment claim audits to identify payment inaccuracies, processing errors, documentation deficiencies, and opportunities for recovery or correction.
Identify trends, recurring errors, system issues, and process deficiencies affecting claim accuracy or financial performance and recommend appropriate corrective action.
Work closely with TPAs and external claims administrators to resolve complex claims issues, validate claim information, and ensure adherence to contractual and administrative requirements.
Manage inquiries and escalated claim matters from brokers, TPAs, plan sponsors, Underwriting, reinsurers, and other stakeholders, providing clear, timely, and professional responses.