Stop Loss Claim Auditor

Job not on LinkedIn

🔥 1 hour ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

👻 Ghost score 10%

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Vālenz® Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2004

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Vālenz® Health is a comprehensive health plan solutions provider that offers a fully integrated platform designed to simplify the complexities of healthcare for employers, payers, providers, and members. The company focuses on enhancing quality and lowering costs through data-driven insights, member navigation, provider networks, and robust claims management. By connecting various stakeholders in the healthcare ecosystem, Vālenz aims to improve health outcomes and streamline the healthcare experience for all involved.

📋 Description

• Review and audit stop loss reimbursement requests for accurate and timely payment • Evaluate claim and eligibility documentation and perform aggregate claim calculations within delegated authority • Retrieve, log, organize, and review stop loss claim submissions and supporting documentation • Audit initial and supplemental reimbursement requests for eligibility, covered expenses, contract terms, deductible application, and plan or policy provisions • Perform preliminary calculations and audits for aggregate accommodations and final year-end aggregate claim submissions • Identify discrepancies, exceptions, ambiguous contract language, and matters outside delegated authority and escalate them appropriately • Obtain and evaluate eligibility, extension-of-benefits, FMLA, COBRA, precertification, accident, subrogation, UB-04, itemized bill, and other supporting documentation • Maintain complete and accurate audit documentation, calculations, determinations, and supporting records in claim systems • Review plan documents, Summary Plan Descriptions, amendments, and related materials using checklists and approved automated or AI-assisted tools • Validate automated and AI-assisted review outputs before using them in claim or plan-document decisions • Identify eligibility, coordination, cost-containment, payment-integrity, and reimbursement issues and coordinate with internal and external partners • Support high-cost claim monitoring, reserve and notification review, and related reporting • Communicate with TPAs, brokers, carriers, auditors, vendors, and internal partners regarding documentation, claim status, findings, and questions • Support claims quality reviews, reporting, research, procedure documentation, and continuous improvement initiatives • Provide backup support for claims intake and workflow activities • Perform duties in accordance with procedures, contractual requirements, delegated authority, confidentiality standards, and regulatory requirements

🎯 Requirements

• 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 • Ability to interpret plan documents, stop loss policies, eligibility information, and claim documentation • Strong analytical and mathematical skills for detailed claim audits and reimbursement calculations • Strong attention to detail and ability to maintain complete, accurate, and audit-ready documentation • Ability to independently review claims within established procedures and delegated authority and escalate exceptions or high-risk matters • Strong organizational and time-management skills • Strong written and verbal communication skills • Proficiency with Microsoft Office applications, including Excel and Word • Ability to learn stop loss administration, underwriting, and reporting systems • Ability to use approved automated and AI-assisted tools responsibly with human review and validation • Ability to handle confidential financial, claim, and member information with discretion • Must be US based and able to comply with company policies such as HIPAA • Bachelor's degree in Healthcare Administration, Accounting, Finance, Insurance, Business, or a related field is a plus • Experience auditing complex or high-dollar medical claims is a plus • Experience reviewing Summary Plan Descriptions, plan documents, stop loss contracts, or amendments is a plus • Experience with aggregate accommodation and year-end aggregate claim calculations is a plus • Experience with self-funded employers, stop loss carriers, TPAs, managing general underwriters, or related healthcare financing organizations is a plus • Experience identifying payment-integrity, cost-containment, subrogation, coordination-of-benefits, or eligibility issues is a plus • Experience with stop loss claims administration, underwriting, or reporting platforms is a plus

🏖️ Benefits

• Generous compensation commensurate with experience and performance • Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401(k) with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection • Necessary equipment provided for fully remote work • Generously subsidized company-sponsored Medical, Dental, and Vision insurance • Access to Healthcare Blue Book and KISx Card services • HSA, FSA, and DCFSA spending account options • Flexible working environment • Generous paid time off, including vacation, sick leave, and paid holidays • Employee Assistance Program with 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

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