Senior Stop Loss Claims Auditor

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $49.4k - $94.7k / 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

• Audit and authorize reimbursement of specific medical stop loss claims • Mitigate client medical stop loss claims and provide customer service • Analyze and adjudicate stop loss claims and request appropriate reimbursement from carriers • Recognize cost mitigation opportunities • Authorize and release stop loss claims reimbursement checks within authority limits • Initiate claims investigations and vendor referrals • Interpret plan language and identify experimental services and subrogation opportunities • Follow up on pended claims and resolve outstanding issues • Communicate with carriers, vendors, and management • Provide claims service for phone and written inquiries • Generate and maintain claims system reports to adjust reserves and identify pending and backlog claims • Provide renewal and enrollment/premium history • Develop new and review existing stop loss claim forms • Assist with internal auditing and training of claims auditors

🎯 Requirements

• Associate's Degree required • 2 years of job-related work experience may serve as the degree equivalency • 6 years of managed care or reinsurance claims experience • Analyze laws, regulations, and contract language • Evaluate issues and develop recommendations • Handle confidential and sensitive information • Investigate assigned claims • Propose claims adjustments and refunds • Work 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