Job description
Who are we?
A strategic and trusted insurance partner, who help our clients reclaim their precious time through our specialized solutions that alleviate the challenges of acquiring authorizations, managing medical coding, rectifying claims complications, and overcoming denials.
We are a values-based organization where respect, integrity, excellence, collaboration, and passion define who we are and how we do business. We value diversity of backgrounds, experience, and perspectives and strive to foster an inclusive environment that enables all our team members to bring their best selves to work. We are one team committed to building a culture where every teammate has the opportunity to contribute and be recognized.
Job Opportunity:
This is an exciting opportunity for Claims Auditor with knowledge of employer group health insurance, managed care, and direct medical claims products. The position is preferably for an individual who is interested in working remotely. We are open to candidates who could work from home anywhere throughout the United States.
Duties & Responsibilities:
- Audit specific and aggregate claims for assigned complex blocks of business
- Audit and process claim reimbursements
- Verify claims are paid in accordance with the plan document and reimbursable under the Stop Loss policy
- Verify participant and dependent eligibility
- Maintain and exceed targeted claims accuracy standards
- Maintain accurate and detailed information for each file
- Conduct implementation calls for newly sold groups
- Review and approve plan documents and plan amendments
- Initiate and further cost containment opportunities
- Audit program business claims across several lines within our Accident & Health Division
- Assist management with implementation calls for new business sold
- Set and adjust reserves
Qualifications, Skills, and Experience:
- Minimum of 5+ years’ experience examining and auditing medical stop loss claims
- Proficient with Microsoft Office Suite, especially Excel
- Knowledge of group insurance, managed care, and direct medical claims products
- Demonstrate excellent mathematical, communication and customer service skills
- Excellent problem-solving and critical-thinking skills
- Detail/results-oriented
- Strong analytical skills
- Excellent customer service
- Knowledge of COB, Medicare, HIPAA, CPT, ICD9/ICD10, and interpretation of employer group health plan benefits
- Ability to work independently with minimal supervision while meeting or exceeding established turn-around-time, production, and accuracy standards