Claims Specialist - Stop-Loss Reimbursement & Analysis

Old Republic Accident & Health; United States; On-site; USD 65,000 - 90,000; Full time

Job summary

Old Republic Accident & Health is seeking a collaborative Claims Specialist to join our fast-growing team. You will process and adjudicate stop-loss claims, make reimbursement decisions, and ensure compliance with applicable laws and policy documents.

Responsibilities include reviewing codes, analyzing claim data, and partnering with underwriters, clinicians, and brokers to meet client needs and maintain high service levels. A Bachelor’s degree and 2–5 years of relevant experience are preferred.

Qualifications

• 2-5 years of stop-loss claims reimbursement experience.
• Experience with claims software (Connexure or UGAN) and CPT and ICD coding knowledge is required.
• Demonstrated ability to manage multiple high-priority projects concurrently, effectively set priorities, and consistently meet tight deadlines.
• Strong communication and interpersonal skills with the ability to effectively convey information at all levels, both verbally and in writing.
• Ability to manage tasks autonomously while also supporting team goals.

Responsibilities

• Process and adjudicate stop loss claims to ensure timely and accurate resolutions.
• Make accurate reimbursement decisions based on policy documents, plan details, and cost containment strategies.
• Authorize and process payment, partial payment, or denial of claim based upon individual investigation and analysis.
• Review billed procedure and diagnosis codes on claims for billing irregularities.
• Ensure compliance with laws and regulations.
• Develop quantitative analyses of claims issues.
• Analyze claim data and trends to identify areas for improvement in the claims process.
• Collaborate with underwriting, clinical, and business development teams to address client needs and provide exceptional service.
• Build and maintain strong relationships with TPAs, vendors, MGUs, brokers, and other stakeholders to ensure high levels of customer satisfaction.

Skills

Stop-loss claims

CPT coding

ICD coding

Communication

Multitasking

Education

Bachelor's degree in business or related field

Tools

Connexure

UGAN

Job description

Old Republic Accident & Health is seeking a collaborative Claims Specialist to join our fast-growing team. You will process and adjudicate stop-loss claims, make reimbursement decisions, and ensure compliance with applicable laws and policy documents.

Responsibilities include reviewing codes, analyzing claim data, and partnering with underwriters, clinicians, and brokers to meet client needs and maintain high service levels. A Bachelor’s degree and 2–5 years of relevant experience are preferred.