[Hiring] Stop Loss Claim Auditor @Valenz

Role Description

As a Stop Loss Claim Auditor, you’ll review and audit stop loss reimbursement requests to ensure accurate and timely payments in accordance with plan documents, stop loss policies, contractual requirements, and established procedures. You’ll evaluate supporting claim and eligibility documentation, perform aggregate claim calculations within your delegated authority, and help ensure reimbursement requests meet applicable requirements. You’ll also support plan document reviews, payment integrity initiatives, reporting, and high-cost claim monitoring to promote accuracy, consistency, and compliance throughout the stop loss reimbursement process.

Things You’ll Do Here

• Review and audit stop loss reimbursement requests to ensure accurate and timely payment in accordance with plan documents, stop loss policies, contractual requirements, and established procedures.
• Evaluate supporting claim and eligibility documentation, perform aggregate claim calculations within delegated authority, and support plan-document review, payment integrity, reporting, and high-cost claim monitoring.
• Retrieve, log, organize, and review stop loss claim submissions and supporting documentation within established turnaround standards.
• Audit initial and supplemental reimbursement requests for eligibility, covered expenses, contract terms, deductible application, and other applicable plan and policy provisions.
• Perform preliminary calculations and audits for aggregate accommodations and final year-end aggregate claim submissions, including review of contract terms, aggregate factors and deductibles, enrollment and premium information, paid claim data, and supporting documentation.
• Identify discrepancies, exceptions, ambiguous contract language, and matters outside delegated authority and escalate them to appropriate Claims, Compliance, Underwriting, or leadership resources.
• Obtain and evaluate supporting documentation, including eligibility records, extension-of-benefits information, FMLA and COBRA documentation, precertification information, accident or subrogation records, UB-04s, itemized bills, and other required materials.
• Maintain complete and accurate documentation of audit activity, information requests, calculations, determinations, and supporting records within applicable claim systems.
• Review plan documents, Summary Plan Descriptions, amendments, and related materials using established checklists and approved automated or AI-assisted tools.
• Validate automated or AI-assisted review outputs before use in claim or plan-document decisions and escalate material discrepancies or uncertainties for additional review.
• Identify potential eligibility, coordination, cost-containment, payment-integrity, or reimbursement issues and coordinate with appropriate internal and external partners.
• Support high-cost claim monitoring, reserve and notification review, and related reporting by evaluating available clinical and financial information.
• Communicate with TPAs, brokers, carriers, auditors, vendors, and internal partners regarding missing documentation, claim status, audit findings, and related questions within established authority.
• Support claims quality reviews, reporting, research, procedure documentation, and continuous improvement initiatives.
• Provide backup support for claims intake and workflow activities as business needs require.
• Perform duties in accordance with established procedures, contractual requirements, delegated authority, confidentiality standards, and applicable regulatory requirements.
• Accommodation may be made to enable individuals with disabilities to perform essential duties.

Qualifications

• 3+ years of experience in healthcare claims, stop loss claims, medical claim auditing, TPA operations, or a related field.
• Working knowledge of self-funded medical plans, employer stop loss terminology, reimbursement processes, contracts, and operational workflows.
• Demonstrated ability to interpret plan documents, stop loss policies, eligibility information, and claim documentation.
• Strong analytical and mathematical skills with the ability to perform detailed claim audits and reimbursement calculations accurately.
• Strong attention to detail with demonstrated ability to maintain complete, accurate, and audit-ready documentation.
• Ability to independently review claims within established procedures and delegated authority and appropriately escalate exceptions or high-risk matters.
• Strong organizational and time-management skills with the ability to manage multiple claims, deadlines, and documentation requirements.
• Strong written and verbal communication skills with the ability to work effectively with TPAs, carriers, brokers, vendors, and internal partners.
• Proficiency with Microsoft Office applications, including Excel and Word, and the ability to learn stop loss administration, underwriting, and reporting systems.
• Ability to use approved automated and AI-assisted tools responsibly while maintaining appropriate human review and validation of outputs.
• Ability to handle confidential financial, claim, and member information with discretion.

Requirements

• A plus if you have a Bachelor’s degree in Healthcare Administration, Accounting, Finance, Insurance, Business, or a related field.
• Experience auditing complex or high-dollar medical claims.
• Experience reviewing Summary Plan Descriptions, plan documents, stop loss contracts, or amendments.
• Experience with aggregate accommodation and year-end aggregate claim calculations.
• Experience with self-funded employers, stop loss carriers, TPAs, managing general underwriters, or related healthcare financing organizations.
• Experience identifying payment-integrity, cost-containment, subrogation, coordination-of-benefits, or eligibility issues.
• Experience with stop loss claims administration, underwriting, or reporting platforms.

Benefits

• Generously subsidized company-sponsored Medical, Dental, and Vision insurance, with access to services through our own products, Healthcare Blue Book and KISx Card.
• Spending account options: HSA, FSA, and DCFSA.
• 401K with company match and immediate vesting.
• Flexible working environment.
• Generous Paid Time Off to include vacation, sick leave, and paid holidays.
• Employee Assistance Program that includes professional counseling, referrals, and additional services.
• Paid maternity and paternity leave.
• Pet insurance.
• Employee discounts on phone plans, car rentals, and computers.
• Community giveback opportunities, including paid time off for philanthropic endeavors.