Senior Stop Loss Claims Auditor

001 BlueCross and BlueShield of South Carolina; Columbia (SC); Remote; USD 49,000 - 95,000; Full time

Benefits offered by this job

Subsidized health plans

401k with company match

Life Insurance

Paid Time Off (PTO)

Education Assistance

Service Recognition

National discounts

Job summary

BlueCross BlueShield of South Carolina is seeking an experienced Summary Audit Specialist to audit and authorize reimbursement of stop loss claims. The role emphasizes mitigating client stop loss risk while providing excellent service. This remote position supports a full-time schedule, Monday–Friday, EST.

Required qualifications include an associate degree or equivalent with 6 years in managed care or reinsurance claims. Benefits and pay range are described in the posting.

Qualifications

• Associates degree or equivalent, plus 2 years of related work experience.
• 6 years of managed care or reinsurance claims experience.

Responsibilities

• Audit and adjudicate stop loss claims and request reimbursement from carrier.
• Identify cost mitigation opportunities.
• Authorize release of stop loss reimbursement checks within authority limits.
• Initiate claims investigations and vendor referrals.
• Interpret plan language and identify experimental services and subrogation opportunities.
• Follow up on pended claims and resolution needs.
• Communicate with carriers, vendors and management.
• Provide full claims service for phone and written inquiries.
• Generate and maintain claims system reports for reserves and renewals.
• Develop and review stop loss claim forms and procedures.
• Assist auditors and train claims auditors.

Skills

Laws & contract analysis

Investigations of claims

Confidential information handling

Claims adjustment & refunds

Claims caseload management

Aggregate claims experience

Education

Associate's Degree or equivalent

Job description

Summary

Summary Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Description Position Purpose Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. Companion Life – one of BlueCross BlueShield's South Carolina subsidiary companies.

Location and Hours

Location: This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm EST and will be fully remote.

What You’ll Do

• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
• Recognize cost mitigation opportunities.
• Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
• Initiate claims investigations and vendor referrals.
• Interpret plan language, and identify experimental services and subrogation opportunities.
• Identify need for follow-up on pended claims and resolution.
• Communicate effectively with carriers, vendors, and management.
• Provide full claims service to both phone and written inquiries.
• Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
• Develop new and review old stop loss claim forms.
• Assist with internal auditing of claims auditors, and training of claims auditors.

Required Qualifications

Required Education: Associate's Degree Equivalency: 2 years of job-related work experience Required Work Experience: 6 years of managed care or reinsurance claims experience.

Preferred Qualifications

• Analyzes laws, regulations and contract language.
• Evaluates issues and develops recommendations.
• Handles confidential and sensitive information.
• Investigates assigned claims.
• Proposes claims adjustments and refunds.
• Works claims caseloads.
• Aggregate claims experience.

Benefits

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

Pay Range Information

Range Minimum $49,447.00 Range Midpoint $72,092.00 Range Maximum $94,737.00

Pay Transparency Statement: Please note that this range represents the pay range for this and other positions that fall into this pay grade. Compensation decisions within the range will be dependent upon a variety of factors, including experience, geographic location, and internal equity.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations. We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company. If you need special assistance or an accommodation while seeking employment, please email [e-mail] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis. We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer.

Company Culture

Welcome Here’s Your Smart Career Move Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but for more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community. Business and political climates may change, but we’re stronger than ever. Our A.M. Best rating is A+ (Superior) - making us the only health insurance company in South Carolina with that rating. We’re the largest insurance company in South Carolina … and much more. We are one of the nation’s leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths. We deliver outstanding service to our customers. Veterans Welcome! BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks. We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more. Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson. If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.