Claims Auditor – Medical Stop Loss

Job not on LinkedIn

🕒 May 21

Apply Now

Find Similar Remote Jobs

Receive Emails For Remote Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Skyward Specialty Insurance

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2007

🤝 B2B

💸 Finance

⚕️ Healthcare Insurance

💰 $177.3M Post-IPO Secondary - Skyward Specialty on 2024-05

B2B • Finance • Healthcare Insurance

Skyward Specialty Insurance is a Houston-based specialty insurance group that provides tailored risk solutions across niche and complex markets. The company offers a range of specialty insurance products including transactional Excess & Surplus (E&S), professional lines, medical stop-loss, surety, captives, programs, global property, agriculture & credit (re)insurance, and risk consulting. Skyward works primarily with brokers and agents, leverages technology (including e-surety capabilities) to deliver innovative underwriting and claims services, and focuses on high-complexity, non-standard risks and scalable specialty solutions.

📋 Description

• Conduct thorough audits of accident and health insurance claims to verify accuracy, policy compliance, and proper adjudication. • Ensure claims adhere to company policies, industry regulations, and legal requirements, including HIPAA. • Analyze claims data to identify patterns, discrepancies, and opportunities for process improvement. • Prepare detailed audit reports and communicate findings, recommendations, and corrective actions to management and relevant departments. • Collaborate with claims processing teams to implement audit recommendations, streamline workflows, and enhance claims accuracy. • Serve as a subject matter expert by training junior auditors and claims processors on audit procedures and compliance standards. • Maintain accurate documentation of audit processes, findings, and follow-up actions, ensuring all information is safeguarded and confidential. • Stay updated on changing regulations, industry best practices, and emerging audit methodologies.

🎯 Requirements

• Bachelor’s degree in business, Insurance, or related field (preferred) • Minimum 3+ years in experience in medical claims auditing and processing in accidental and health insurance claims. • Robust knowledge of claims processing systems, protocols, and regulatory requirements. • Excellent analytical, problem-solving, and decision-making skills. • Strong attention to detail and organizational abilities. • 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. • Effective problem-solving, team partnership, and project management abilities • Proficiency with claims processing systems and Microsoft Office Suite (Word, Excel, PowerPoint)

🏖️ 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