Stop Loss Auditor

Lucent Health; Nashville (TN); Vor Ort; USD 55.000 - 75.000; Vollzeit

Zusammenfassung

Lucent Health in Nashville, TN is seeking a Stop Loss Analyst to support administration, monitoring, and reimbursement recovery of stop loss claims for self-funded employer groups. You will identify high-cost claimants, audit eligibility, prepare submissions, and maintain documentation to ensure timely recovery and compliance with policy requirements.

This role requires collaboration with carriers, brokers, account management, underwriting, and client service teams, along with strong data

Qualifikationen

• High school diploma or equivalent required; associate or bachelor’s degree preferred.
• 1–3 years of stop loss, medical claims, benefits administration, or related experience.
• Working knowledge of self-funded health plans and stop loss concepts.
• Ability to review claim detail reporting and reconcile data.
• Proficiency with Outlook, Word, and Excel.
• Strong attention to detail, organization, and communication.
• Ability to manage multiple priorities in a fast-paced TPA environment.
• Commitment to confidentiality and client service.

Aufgaben

• Monitor claim activity and identify members approaching or exceeding deductible thresholds and high-cost claimants.
• Review paid medical and pharmacy claims, eligibility records, plan documents, and stop loss policy provisions for eligibility and accuracy.
• Prepare and submit complete reimbursement requests to stop loss carriers with supporting documentation.
• Track pending, outstanding, reimbursed, denied, and pended claims; coordinate with carriers and internal teams to resolve items.
• Process reimbursement payments from stop loss carriers and coordinate with accounting and claims teams.
• Support monthly and year-end aggregate reporting, accommodation requests, and claim reconciliations.
• Serve as liaison between internal teams, stop loss carriers, brokers, account management, underwriting, and clients.
• Maintain accurate electronic claim files, tracking logs, and audit-ready documentation.
• Assist with audits, quality reviews, renewal analysis, and data/trend insights for clients.
• Identify process gaps and recommend improvements to enhance efficiency and service.

Kenntnisse

Stop loss knowledge

Claims analysis

Healthcare operations

Data reconciliation

Attention to detail

Communication skills

Multitasking

Ausbildung

High school diploma or equivalent

Associate or bachelor’s degree in business, healthcare administration, finance, accounting, or a related field

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Jobbeschreibung

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Lucent Health combines top-tier claims management with a compassionate, human-focused, data-driven care management solution. This approach helps self-insured employers provide care management that enables health plan participants to make smarter, cost-saving healthcare decisions. Continuous data analytics offer ongoing insights, ensuring participants receive the right care, at the right cost, at the right time. Join us as we build a company that aims to be a better health benefits partner for self-insured employers.

Summary

The Stop Loss Analyst supports the administration, monitoring, and reimbursement recovery of specific and aggregate stop loss claims for self-funded employer groups serviced by Lucent Health. This role holds the responsibility for identifying high-cost claimants, auditing claim and eligibility information, preparing reimbursement submissions, tracking carrier activity, and maintaining accurate documentation to support timely recovery and compliance with stop loss policy requirements.

Responsibilities

• Monitor claim activity to identify members approaching or exceeding specific deductible thresholds, including early identification of high-cost claimants.
• Review paid medical and pharmacy claims, fees, eligibility records, plan documents, and stop loss policy provisions to confirm reimbursement eligibility and accuracy.
• Prepare, organize, and submit complete reimbursement requests to stop loss carriers, managing required documentation such as claim detail, eligibility verification, paid claim reports, disclosure information, and supporting correspondence.
• Track pending, outstanding, reimbursed, denied, and pended claims; follow up with carriers, vendors, internal teams, and clients as needed to resolve open items.
• Process reimbursement payments received from stop loss carriers and coordinate with accounting, finance, claims, or client service teams to ensure accurate application and reporting.
• Support monthly and year-end aggregate reporting, accommodation requests, and claim reconciliation processes.
• Serve as a liaison between internal TPA operations, stop loss carriers, brokers, account management, underwriting, and client-facing teams regarding claim status, documentation needs, and reimbursement issues.
• Maintain accurate electronic claim files, tracking logs, reports, and audit-ready documentation in accordance with internal procedures and carrier requirements.
• Assist with internal audits, quality reviews, renewal analysis, disclosure updates, and sales or implementation support by providing stop loss claim data and trend insights.
• Identify process gaps, recurring documentation issues, or reimbursement delays and recommend improvements to strengthen operational efficiency and client service.

Qualifications

• High school diploma or equivalent required; associate or bachelor’s degree in business, healthcare administration, finance, accounting, or a related field preferred.
• One to three years of experience in stop loss, medical claims, benefits administration, healthcare operations, TPA operations, or a related field preferred.
• Working knowledge of self-funded health plans, specific and aggregate stop loss, claim funding, reimbursement processes, eligibility, and plan document requirements preferred.
• Ability to review medical and prescription drug claim detail reporting, interpret policy and plan provisions, reconcile data, and identify documentation needed to support reimbursement.
• Proficiency with Microsoft Outlook, Word, and Excel.
• Strong attention to detail, organization, follow-through, and analytical problem-solving skills.
• Clear written and verbal communication skills with the ability to collaborate across claims, account management, finance, underwriting, carriers, brokers, and clients.
• Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced TPA environment.
• Commitment to confidentiality, accuracy, compliance, and excellent service for clients and members.

Company Culture

At Lucent Health, our success is built on employees who are honest, ethical and hardworking. We communicate transparently, act with integrity, and hold ourselves accountable for our work and decisions. We treat colleagues, clients and partners with fairness, respect and confidentiality. And we bring consistency, initiative and adaptability to everything we do, taking ownership of challenges and going the extra mile when it counts.

Lucent Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, color, creed, religion, alienage or national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity, gender expression, transgender status, sexual orientation, marital status, military service and veteran status.