Senior Stop-Loss Claims Auditor — Remote

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

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.