Claims Auditor – Stop Loss, Aggregate

🕒 3 days ago

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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

• Review and validate medical stop loss aggregate claim reimbursements by auditing claim data, eligibility, plan provisions, and contract terms • Audit aggregate stop loss submissions (weekly/monthly/quarterly/annual) to confirm accuracy • Confirm appropriate treatment of: Coordination of Benefits (COB), subrogation, third-party recovery offsets, Provider credits/refunds, Rx rebates (if contractually relevant) • Reconcile eligibility/enrollment counts • Review Plan & Contract Interpret - Stop loss policy/certificate, endorsements, and amendments • Communicate with underwriting, TPA’s, brokers/producers to resolve discrepancies

🎯 Requirements

• 2+ years of experience of Stop loss Aggregate claim handling • Working knowledge of: Aggregate stop loss concepts (attachment points, factors, contract basis, reimbursements), Medical claims components (allowed vs. paid, reversals/adjustments, claim timing), Eligibility/enrollment reconciliation • Funding verification • Strong analytical skills with attention to detail and ability to interpret plan/contract language • Proficiency with Excel (pivot tables, XLOOKUP/VLOOKUP, filtering, data validation; comfort with large datasets)

🏖️ 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 • Other employee assistance