Supervisor, Claims Audit - Accident & Health
About The Position
The Supervisor, Claims Audit – A&H Core Team, is responsible for leading a team of claims auditors focused on reviewing and rendering decisions on liability for claims made under Medical Stop Loss policies issued to Skyward non captive insurance clients. This role oversees the claims audit process for accident and health captive programs, ensuring claims are handled accurately, efficiently, and in accordance with company standards and client expectations. The manager will guide and support staff, ensure compliance with audit protocols, and partner with stakeholders to drive quality results and client satisfaction. This position will work a hybrid schedule in our Kennesaw, GA office.
Requirements
- Bachelor’s degree in business, Insurance, or related field (preferred)
- 5-7+ years of progressive experience in medical claims auditing and processing, including experience in a supervisory or lead role within the stop loss insurance industry.
- Experience managing claims teams working with accident and health insurance programs.
- Demonstrated expertise in medical stop loss claims audit; experience with aggregate claims is highly desirable.
- Advanced knowledge of claims processing guidelines, medical terminology (ICD-10, CPT, HCPCS, UB04), and insurance concepts (UCR, COB, HIPAA, subrogation)
- Familiarity with eligibility guidelines and group health plan administration (Medicare, COBRA, FMLA, etc.)
- Strong analytical skills with attention to detail and proficiency in interpreting Plan Documents and reinsurance contracts
- Excellent written and verbal communication skills with proven customer service leadership
- Effective problem-solving, team leadership, and project management abilities
- Proficiency with claims processing systems and Microsoft Office Suite (Word, Excel, PowerPoint)
- Ability to foster a collaborative team environment and drive continuous improvement initiatives
Responsibilities
- Supervise, train, and mentor the Claims Audit team, ensuring adherence to claims audit standards and achievement of performance goals
- Oversee audits of medical claims across Skyward insurance programs (monitoring over/under payments, duplicate payments, contract compliance, coordination of benefits, etc.)
- Review and authorize recommendations and decisions on claim reimbursements, denials, or requests for additional information
- Ensure accurate maintenance of documentation within claim files and compliance with regulatory and contractual requirements
- Track and evaluate team productivity, turnaround time, claims accuracy, and client satisfaction metrics; implement improvements as necessary
- Collaborate with clients, brokers, internal departments, and external vendors to resolve complex claims issues and optimize audit outcomes
- Maintain advanced knowledge of medical stop loss claims, insurance regulations, and insurance program structures
- Oversee quality assurance checks and participate in special projects or process enhancements as assigned
Benefits
- health and welfare benefits
- tuition and professional certification assistance
- 401k savings
- elective participation in the Employee Stock Purchase Program
- paid time off
- paid holidays
- child bonding leave
- employee assistance
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What This Job Offers
Job Type
Full-time
Career Level
Manager
