Reinsurance Claim Analyst - REMOTE

S&S Healthcare; Oregon; Hybrid; USD 60,000 - 90,000; Full time

Job summary

Reflect Health is seeking an experienced claims professional to support stop loss claim management and cross-department collaboration. The role emphasizes accuracy in documentation, timely submissions, and strong communication with internal teams and external clients.

The candidate should have experience in medical claims processing, familiarity with reinsurance terms like TLO and Aggregating Specific Deductible, and solid Excel/Office 365 skills.

Qualifications

• Experience in medical claims processing, with a preference for experience in reinsurance.
• Familiarity with reinsurance policies and terms such as TLO (Specific Stop Loss), Aggregating Specific Deductible.
• Strong critical thinking skills and the ability to effectively evaluate and manage complex data and claims.
• Proven ability to manage multiple tasks, prioritize responsibilities, and work independently in a fast-paced environment.
• Intermediate proficiency with Microsoft Office 365, including Excel, Visio, and Word. Experience with claims management systems is a plus.
• Detail-oriented with a keen attention to detail and accuracy in all aspects of work.
• Excellent verbal and written communication skills, with the ability to present complex information clearly.
• Strong analytical and problem-solving skills, with the capacity to articulate issues and propose effective solutions.

Responsibilities

• Reinsurance Policy Setup and Management: Review stop loss policies and ensure accurate setup within claims management systems.
• Claims Documentation and Submission: Collect and verify all necessary documentation for stop loss claims and timely reimbursement submissions.
• Claims Filing and Tracking: Assist in managing specific and aggregate claims submissions, ensuring timely filing of routine and complex claims.
• Cross-Department Collaboration: Work with Operations, Finance, and Sales to provide updates on claim status.
• Account Monitoring and Reporting: Monitor accounts for compliance with reporting requirements and data uploads.
• Financial Application of Claims: Evaluate claim refunds and ensure dollars are applied to appropriate claims.
• Internal and External Communication: Communicate claim decisions clearly to internal teams and external clients.

Skills

Medical claims processing

Reinsurance knowledge

Analytical thinking

Project management

Detail-oriented

Communication skills

Problem solving

Tools

Microsoft Office 365

Claims management systems

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.

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.