[Hiring] Senior Stoploss Claim Auditor @BlueCross BlueShield of South Carolina

Role Description

Audit and authorize reimbursement of specific and/or aggregate medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service.

This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm EST and will be fully remote.

What You’ll Do:

• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
• Recognize cost mitigation opportunities.
• Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
• Initiate claims investigations and vendor referrals.
• Interpret plan language, and identify experimental services and subrogation opportunities.
• Identify need for follow-up on pended claims and resolution.
• Communicate effectively with carriers, vendors, and management.
• Provide full claims service to both phone and written inquiries.
• Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
• Develop new and review old stop loss claim forms.
• Assist with internal auditing of claims auditors, and training of claims auditors.

Qualifications

• Required Education: Associate's
• Required Work Experience: 6 years of managed care or reinsurance claims experience.

Requirements

• Preferred Skills and Abilities:
• Analyzes laws, regulations and contract language.
• Evaluates issues and develops recommendations.
• Handles confidential and sensitive information.
• Investigates assigned claims.
• Proposes claims adjustments and refunds.
• Works claims caseloads.
• Aggregate claims experience.

Benefits

• Subsidized health plans, dental and vision coverage.
• 401k retirement savings plan with company match.
• Life Insurance.
• Paid Time Off (PTO).
• On-site cafeterias and fitness centers in major locations.
• Education Assistance.
• Service Recognition.
• National discounts to movies, theaters, zoos, theme parks and more.