Stop Loss Auditor

Lucent Health Solutions LLC•Nashville, TN

About The Position

The Stop Loss Analyst supports the administration, monitoring, and reimbursement recovery of specific and aggregate stop loss claims for self-funded employer groups serviced by Lucent Health. The role identifies high-cost claimants, audits claim and eligibility information, prepares reimbursement submissions, tracks carrier activity, and maintains accurate documentation to support timely recovery and compliance with stop loss policy requirements. The position also coordinates reimbursement payments and reporting with internal teams, supports aggregate reporting and reconciliation, and serves as a liaison among internal operations, carriers, brokers, account management, underwriting, and clients. It contributes to audits, quality reviews, renewal analysis, disclosure updates, and process improvements.

Requirements

High school diploma or equivalent required.
One to three years of experience in stop loss, medical claims, benefits administration, healthcare operations, TPA operations, or a related field preferred.
Ability to review medical and prescription drug claim detail reporting, interpret policy and plan provisions, reconcile data, and identify documentation needed to support reimbursement.
Proficiency with Microsoft Outlook, Word, and Excel.
Strong attention to detail, organization, follow-through, and analytical problem-solving skills.
Clear written and verbal communication skills and ability to collaborate across claims, account management, finance, underwriting, carriers, brokers, and clients.
Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced TPA environment.
Commitment to confidentiality, accuracy, compliance, and excellent service for clients and members.

Nice To Haves

Associate or bachelor’s degree in business, healthcare administration, finance, accounting, or a related field.
Working knowledge of self-funded health plans, specific and aggregate stop loss, claim funding, reimbursement processes, eligibility, and plan document requirements.

Responsibilities

Monitor claim activity to identify members approaching or exceeding specific deductible thresholds, including early identification of high-cost claimants.
Review paid medical and pharmacy claims, fees, eligibility records, plan documents, and stop loss policy provisions to confirm reimbursement eligibility and accuracy.
Prepare, organize, and submit complete reimbursement requests to stop loss carriers, including required claim detail, eligibility verification, paid claim reports, disclosure information, and supporting correspondence.
Track pending, outstanding, reimbursed, denied, and pended claims; follow up with carriers, vendors, internal teams, and clients to resolve open items.
Process reimbursement payments from stop loss carriers and coordinate with accounting, finance, claims, or client service teams to ensure accurate application and reporting.
Support monthly and year-end aggregate reporting, accommodation requests, and claim reconciliation processes.
Liaise with internal TPA operations, stop loss carriers, brokers, account management, underwriting, and client-facing teams regarding claim status, documentation needs, and reimbursement issues.
Maintain accurate electronic claim files, tracking logs, reports, and audit-ready documentation in accordance with internal procedures and carrier requirements.
Assist with internal audits, quality reviews, renewal analysis, disclosure updates, and sales or implementation support by providing stop loss claim data and trend insights.
Identify process gaps, recurring documentation issues, or reimbursement delays and recommend improvements to strengthen operational efficiency and client service.