Medical Stop Loss Claims Auditor

Evolution Risk Partners, LLC; Evanston (IL); On-site; USD 60,000 - 80,000; Full time

Benefits offered by this job

Health insurance

401(k)

401(k) matching

Flexible PTO

Wellness programs

Job summary

Evolution Risk Partners, LLC is looking for a Stop Loss Claims Auditor or Senior Stop Loss Claims Auditor in Evanston, Illinois. The role involves auditing and authorizing reimbursements for medical claims while ensuring exceptional customer service.

The ideal candidate will have 3-5+ years of experience in Stop Loss Claims Auditing and medical claim processing, with a strong analytical background. We offer a competitive salary, generous PTO, health insurance, and a 401(k) with match.

Qualifications

• 3-5+ years of experience in auditing medical Stop Loss Claims.
• Ability to analyze claims and large claim management reports.
• Excellent verbal and written communication skills.

Responsibilities

• Audit and authorize reimbursements of claims.
• Timely follow-up of pending claims.
• Recognize cost mitigation opportunities.

Skills

Medical claim processing

Stop Loss Claims Auditing

Analytical skills

Customer service

Proficient in Excel

Education

Bachelor’s degree

Job description

Stop Loss Claims Auditor or Senior Stop Loss Claims Auditor

The Stop Loss Auditor is responsible for auditing and authorizing reimbursements of specific claims and effectively mitigate client medical stop loss claims and provide excellent customer service.

Experience/Qualifications

• 3-5+ years of experience in auditing medical Stop Loss Claims.
• Audit stop loss claims and verify claims are paid in accordance with the Plan Document and reimbursable under the stop loss contract.
• Timely follow-up of pending claims to ensure additional information is received.
• Recognize cost mitigation opportunities.
• Interpret plan languages and stop loss contracts.
• Familiar with the process of referring claims for over-authority review and approval to the carrier.
• Efficient communication with both internal and external customers
• Experience with auditing aggregate claims
• Captive experience a plus
• Ability to analyze claims and/or large claim management reports to post and/or adjust reserves.

Skills/Abilities

• 2-3 years medical claim processing or 3-5+ years Stop Loss Claims Auditing and reinsurance experience.
• Bachelor’s degree a plus.
• Experience TPA Claims Processing and cost mitigation.
• Proficient in Excel (for example: sorting, filtering, data, creating pivot tables.)
• Ability to interpret and understand Plan Document wording and the application of provisions including eligibility.
• Knowledge in COB, Medicare rules, CPT codes, REV codes, ICD-10 codes, HCPCS codes, J-codes
• Excellent customer service, organizational with strong analytical skills
• Detail/results-oriented
• Ability to work independently with minimal supervision while meeting or exceeding established production and accuracy standards.
• Ability to interpret and understand Stop Loss Contracts
• Customer Service focused.
• Excellent verbal and written communication skills

What We Offer

We're proud to offer a competitive salary, generous and flexible PTO & paid holidays, 401(k) with match, exclusive discount programs, health & wellness programs, and more.

Benefits

• Health insurance
• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health savings account
• Life insurance
• Vision insurance