Stop Loss Claims Analyst

CVS Health

1d•Onsite

About The Position

The Stop Loss Claims Analyst supports stop loss claim filing activity for a portfolio of self-funded employer groups and clients. This role involves preparing, tracking, reconciling, and helping generate and marshal stop loss filings to completion while serving as a key liaison across internal business partners, external stakeholders, and stop loss carriers. The position offers exposure to many areas of healthcare claims administration, including stop loss and reinsurance policy, data analytics, underwriting, eligibility, finance, client management, and provider and broker relations. It is well suited for someone who is detail-oriented, analytical, highly organized, and motivated to build expertise in a specialized area of the healthcare industry. Training is available for the right candidate who is ready to learn, grow, and develop in the role.

Requirements

Minimum of 2 years of experience in healthcare claims processing or a related health insurance environment
Minimum of 2 years of experience using Microsoft Office applications, particularly Excel
Strong analytical, problem-solving, and organizational skills
Strong verbal and written communication skills
Ability to work independently and collaboratively across a matrixed team in a fast-paced environment
Strong attention to detail and ability to manage multiple priorities and deadlines

Nice To Haves

Stop loss or reinsurance experience
Experience preparing or supporting stop loss claim filings
Experience reviewing plan documents, policy provisions, or reimbursement-related documentation
Exposure to IBM AIX or AS/400 mainframe environments

Responsibilities

Prepare, update, and submit stop loss filing packages, including initial, subsequent, and year-end filings as needed
Track claim activity and follow up through to completion with stop loss carriers and other stakeholders to help ensure reimbursements are received accurately and timely
Monitor assigned employer groups and clients using reports, analysis, and reimbursement activity trends
Assist in researching and reconciling discrepancies between requested reimbursement amounts and amounts returned by stop loss carriers
Serve as an advocate for clients by helping capture the maximum eligible reimbursements available under applicable stop loss policies
Review claim documentation for completeness, accuracy, and alignment with policy provisions and filing requirements
Monitor assigned employer groups and clients using reports, analysis, and reimbursement activity trends
Research and resolve cases that require additional analysis, documentation, or explanation
Communicate with internal and external stakeholders to obtain information, resolve issues, and support timely filing resolution
Partner with cross-functional teams, including areas such as underwriting, finance, eligibility, and client support, to facilitate filing resolution
Maintain accurate records, logs, and supporting documentation related to assigned stop loss filings and reimbursements
Escalate complex issues or delays appropriately and support process improvement efforts when trends or gaps are identified