Senior Stoploss Claim Auditor

🔥 4 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $51.1k - $97.7k / year

⏰ Full Time

🟠 Senior

🔎 Auditor

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BlueCross BlueShield of South Carolina

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1946

🏥 Healthcare

💼 Consulting

⚖️ Legal

Healthcare • Consulting • Legal

BlueCross BlueShield of South Carolina is a leading health insurance provider that offers a variety of health plans, including individual and family plans, Medicare options, and group health plans. The organization focuses on providing coverage and resources for members, employers, and healthcare providers, ensuring access to quality healthcare services. With a commitment to promoting healthier lifestyles and supporting community health, BlueCross BlueShield of South Carolina plays a vital role in the healthcare landscape of the region.

📋 Description

• 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.

🎯 Requirements

• Required Education: Associate's degree • Degree Equivalency: 2 years of job related work experience • Required Work Experience: 6 years of managed care or reinsurance claims experience. • 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

🏖️ Benefits

• We understand the value of a diverse and inclusive workplace • Opportunity to develop skills • Advance careers • Contribute unique abilities to the growth of the company