Sr Stoploss Claim Auditor-2
About The Position
Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. BlueCross BlueShield of South Carolina has been part of the national landscape for more than seven decades, with its roots firmly embedded in the South Carolina community. They are the largest insurance company in South Carolina and one of the nation's leading administrators of government contracts. They operate one of the most sophisticated data processing centers in the Southeast and have a diverse family of subsidiary companies, allowing them to build on various business strengths. They deliver outstanding service to their customers.
Requirements
- Associate's degree
- 2 years of job related work experience
- 6 years of managed care or reinsurance claims experience.
- Analyzes laws, regulations and contract language.
- Evaluates issues and develops recommendations.
- Handles confidential and sensitive information.
- Investigates assigned claims.
- Proposes claims adjustments and refunds.
- Works claims caseloads
Responsibilities
- Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
- Recognize cost mitigation opportunities.
- Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
- Initiate claims investigations and vendor referrals.
- Interpret plan language, and identify experimental services and subrogation opportunities.
- Identify need for follow-up on pended claims and resolution.
- Communicate effectively with carriers, vendors, and management.
- Provide full claims service to both phone and written inquiries.
- Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
- Develop new and review old stop loss claim forms.
- Assist with internal auditing of claims auditors, and training of claims auditors.
Benefits
- We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
