Senior Stoploss Claim Auditor (Remote)

BlueCross BlueShield of South Carolina; United States; Remote; USD 55,000 - 75,000; Full time

Job summary

A leading company in the insurance sector seeks a Claims Auditor to analyze and authorize medical stop-loss claims. This full-time remote role requires strong analytical and customer service skills, with a focus on effective communication and claims management. Join a team committed to excellence and client satisfaction, while enjoying benefits like health coverage and a 401(k) plan.

Benefits

Health, dental, vision coverage

401(k) with company match

Life insurance

PTO

Education assistance

Qualifications

• Six years of medical or reinsurance claims experience required.
• Preferred: prior stop-loss insurance experience.

Responsibilities

• Analyze and adjudicate stop-loss claims.
• Communicate effectively with carriers and vendors.
• Develop and review stop-loss claim forms.

Skills

Customer Service

Organizational Skills

Analytical Skills

Critical Thinking

Education

Associate Degree

Tools

Microsoft Office

Job description

Summary

This role is responsible for auditing and authorizing reimbursement of specific medical stop-loss claims. The role effectively mitigates client medical stop-loss claims and provides excellent customer service.

Founded in 1991, International Specialty Underwriters, Inc. (ISU) provides exceptional service to the stop loss industry, including claims, underwriting, marketing, and administration. ISU became part of Companion Life Insurance Company in 2008. This integration has enabled ISU to sustain success and growth in a changing marketplace while maintaining the flexibility of the MGU entrepreneur model.

Our commitment to excellence in service, people, and product guides our ongoing success. Our employees are dedicated to delivering this excellence daily. We aim to understand each client's goals and business models to support them with aligned strategies to meet shared objectives.

ISU prides itself on its detailed Carrier Business Model, designed to understand operational, financial, and marketing strategies to stand out from competitors and serve clients better. The company markets, underwrites, and services stop-loss clients nationwide through direct marketing and backroom/white paper operations.

With over 30 years of combined industry experience among its leadership, ISU offers clients distinctive expertise in executive management, underwriting, marketing, administration, and claims.

Description

Logistics:

• Full-time position (40 hours per week), approved for telework/remote work within the United States.
• Travel to training locations and limited travel to client sites as needed.

What You'll Do:

• Analyze and adjudicate stop-loss claims, request reimbursement from carriers, recognize cost mitigation opportunities, and authorize claims payments within authority limits.
• Initiate claims investigations, refer vendors, interpret plan language, and identify opportunities for subrogation and experimental services.
• Follow up on pending claims and resolve issues.
• Communicate effectively with carriers, vendors, and management, providing full claims service via phone and written inquiries.
• Generate and maintain claims system reports for reserve adjustments, pending/backlog claims, and renewal/premium history.
• Develop and review stop-loss claim forms, assist with internal audits, and train claims auditors.

Qualifications:

• Associate degree or two years of medical/reinsurance claims experience required.
• Six years of medical or reinsurance claims experience required.
• Preferred: prior stop-loss insurance experience, high customer service orientation, working knowledge of medical terminology.
• Skills: excellent customer service, organizational, critical-thinking, analytical skills, and proficiency in Microsoft Office.
• Knowledge of group insurance, managed care, COB, Medicare, HIPAA, CPT, ICD-9, and benefit plan interpretation.
• Ability to work independently, persuade, negotiate, and influence others.

Work Environment:

This is a telework/remote position within the U.S., with travel as needed.

Benefits:

• Health, dental, vision coverage
• 401(k) with company match
• Life insurance
• PTO
• On-site amenities in major locations
• Education assistance
• Discounts and recognition programs

Our Commitment:

We value diversity and inclusion, offering opportunities for skill development, career advancement, and contribution of unique abilities.

Next Steps:

After application submission, our team reviews resumes and may contact candidates for verification or interviews, prioritizing those with preferred qualifications.

We participate in E-Verify, comply with pay transparency, and are an Equal Opportunity Employer.

Contact and Legal Notices:

For accommodations or assistance, email [e-mail] or call 800-288-2277, ext. 47480. We comply with applicable laws and promote equal employment opportunities. Additional legal and nondiscrimination statements are included.