Sr Stoploss Claim Auditor-1
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. It is the largest insurance company in South Carolina and one of the nation's leading administrators of government contracts. It operates one of the most sophisticated data processing centers in the Southeast and has a diverse family of subsidiary companies. The company delivers outstanding service to its customers. This position is with Companion Life, an Insurance Company based in Columbia, SC, and a subsidiary of BlueCross BlueShield of South Carolina.
Requirements
- Associate's degree
- 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
- Pay Transparency Statement: Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.
- Equal Employment Opportunity Statement: BlueCross BlueShield of South Carolina and its subsidiary companies maintain a continuing policy of nondiscrimination in employment.
- As a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.
- Commitment to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs.
- Participation in E-Verify and compliance with the Pay Transparency Nondiscrimination Provision.
- Support for veterans, with potential for pay difference coverage if called to active duty for full-time employees in the National Guard or Reserves.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
Associate degree
