Stop Loss Claims Auditor

Berkley•San Antonio, TX

1d•Hybrid

About The Position

Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With our entrepreneurial culture and a strong emphasis on analytics, we can help employers better manage their risk. We offer a broad range of products, including employer stop loss, benefit captives, provider stop loss, HMO reinsurance, and specialty accident. The key to Berkley’s success is our nimble approach to risk – our ability to quickly understand, think through, and devise a plan that addresses each client’s challenges, coupled with the strong backing of a Fortune 500 company. Our parent company, W. R. Berkley Corporation, is one of the largest and best managed property/casualty insurers in the United States. As a Stop Loss Claims Auditor (a.k.a. "Claims Analyst"), you'll perform quality review and evaluation of all claim submissions received and logged into our claims system to determine whether the amount requested is eligible for reimbursement. This position can either be fully remote (if not within commutable distance to the office) or based in one of our offices: Hamilton Square, NJ West Hartford, CT Marlborough, MA Harleysville, PA We offer hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.

Requirements

3-5+ years stop loss claims experience
Prior experience handling first dollar payer insurance (medical healthcare claims)
Experience with medical billing practices, CPT codes, revenue codes, and/or universal billing
Ability to use mathematics to adjudicate claims
Detail oriented with a high degree of accuracy and ability to multitask
Strong problem solving, decision-making, reporting and analytical skills
Must possess good judgment and work effectively with internal business areas, peers and co-workers
Demonstrated proficiency in Microsoft Office software

Nice To Haves

Prior experience handling stop loss claims at the reinsurance level (medical healthcare claims)
Ability to work independently, prioritize, organize and assign own work to meet deadlines
Ability to accept changing priorities with a minimum of disruption

Responsibilities

Process an average of 5 to 7 claims per day
Maintain a processing accuracy of 99% or better
Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim
Review and adjudicate claims within approved authority limits
Maintain assigned claim block and assist other team members while meeting departmental guidelines
Document rationale of claim decisions based on review of the contractual provisions, plan specifications and the analysis of medical records, etc.
Elevate issues to next level of supervision, as appropriate
Other duties as assigned

Benefits

competitive compensation
paid time off
comprehensive wellness benefits and programs
employer funded health savings account
profit sharing
401k
paid parental leave
employee stock purchase plan
tuition assistance and professional continuing education
Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and generous profit-sharing plan