Reinsurance Claim Analyst

S&S Healthcare; Cincinnati (OH); On-site; USD 70,000 - 90,000; Full time

Job summary

Reflect Health in Mason, OH is seeking a Reinsurance Claims Analyst to manage and coordinate stop loss claims, gather documentation, and drive accurate submissions. You will work with Operations, Finance, and Sales to ensure timely processing and clear communication with clients.

The role requires experience in medical claims processing, knowledge of reinsurance concepts, and strong analytical skills. This position offers a full-time on-site role with potential growth in a national organization.

Qualifications

• Experience in medical claims processing, with preference for reinsurance.
• Familiarity with reinsurance concepts such as TLO and Aggregating Specific Deductible.
• Strong analytical and problem-solving abilities.

Responsibilities

• Set up and manage stop loss policies in claims systems.
• Collect and verify documentation for stop loss claims.
• Assist in filing and tracking specific and aggregate claims.
• Collaborate with Operations, Finance, and Sales to update claim status.
• Monitor accounts for compliance and accurate premium remittance.
• Evaluate claim refunds and ensure proper application to claims.
• Communicate claim decisions clearly to internal and external stakeholders.

Skills

Medical claims processing

Reinsurance knowledge

Analytical skills

Project management

Microsoft Office 365

Tools

Claims management systems

Excel

Visio

Word

Job description

Job Description

Job Description

Reflect Health is the evolution of S&S Health, a trusted independent third-party administrator founded in 1994 to meet the growing need for access, simplified connectivity, and benefits administration. Headquartered in Mason, OH, we have built a reputation based on innovation, service excellence, and a deep understanding of how to drive better outcomes at lower cost. Over the years, we grew into a national presence serving employers, TPAs, health systems, and benefit consultants across all 50 states. We developed proprietary claims technology, expanded our offerings to include level-funded and fully funded programs, and delivered tangible savings and enhanced experiences for millions of members.

Reinsurance Claims Analyst plays a crucial role in the management of reinsurance processes, tracking, and reporting for our clients. This position will support the timely filing of reimbursement claims and collaborate with multiple departments to ensure accurate processing and documentation. The Reinsurance Claims Analyst will be responsible for coordinating data, ensuring compliance, and maintaining strong relationships with both internal and external stakeholders.

Key Responsibilities

• Reinsurance Policy Setup and Management: Review stop loss policies and ensure accurate setup within claims management systems. Verify policy terms and conditions, including TLO (Specific Stop Loss) and Aggregating Specific Deductible.
• Claims Documentation and Submission: Collect and verify all necessary documentation for stop loss claims, including eligibility documentation, medical records, subrogation details, and cost containment reports. Ensure all information is accurate and timely for reimbursement submissions.
• Claims Filing and Tracking: Assist in managing specific and aggregate claims submissions, ensuring the timely and accurate filing of both routine and complex stop loss claims.
• Cross-Department Collaboration: Work with internal departments, including Operations, Finance, and Sales, to provide updates on claim status and ensure seamless communication throughout the claims process.
• Account Monitoring and Reporting: Regularly monitor accounts to ensure compliance with reporting requirements. Track premium remittances, and ensure accurate data is uploaded to the system in a timely manner.
• Financial Application of Claims: Evaluate claim refunds and ensure that dollars are properly applied to respective claims filings.
• Internal and External Communication: Articulate claim decisions clearly to both internal teams and external clients based on policy guidelines and group plan documentation.

Qualifications

• Experience: Experience in medical claims processing, with a preference for experience in reinsurance.
• Reinsurance Knowledge: Familiarity with reinsurance policies and terms such as TLO (Specific Stop Loss), Aggregating Specific Deductible, and other related concepts.
• Analytical Skills: Strong critical thinking skills and the ability to effectively evaluate and manage complex data and claims.
• Project Management: Proven ability to manage multiple tasks, prioritize responsibilities, and work independently in a fast-paced environment.
• Technical Skills: Intermediate proficiency with Microsoft Office 365, including Excel, Visio, and Word. Experience with claims management systems is a plus.
• Detail-Oriented: Highly organized with a keen attention to detail and accuracy in all aspects of work.
• Communication Skills: Excellent verbal and written communication skills, with the ability to present complex information in an understandable manner to both internal and external parties.
• Problem-Solving Ability: Strong analytical and problem-solving skills, with the capacity to articulate issues and propose effective solutions.

Reflect Health is committed to providing a safe and secure workplace for all employees. Please note that all final candidates will undergo a comprehensive background check and drug testing as part of our hiring process.