BlueCross BlueShield of South Carolina logo
BlueCross BlueShield of South Carolina

South Carolina’s largest and oldest health insurance company

Senior Auditor, Stoploss Claim

AuditorAuditorFull TimeRemoteSeniorTeam 10,001+Since 1946H1B No SponsorCompany SiteLinkedIn

Location

Hawaii + 2 moreAll locations: Hawaii, Utah, Vermont

Posted

5 days ago

Salary

$51.1K - $97.7K / year

Seniority

Senior

Associate Degree6 yrs expEnglish

Job Description

• Audit and authorize reimbursement of specific medical stop loss claims. • Effectively mitigate client medical stop loss claims and provide excellent customer service. • 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.

Job Requirements

  • Required Education: Associate's
  • Required Work Experience: 6 years of managed care or reinsurance claims experience.
  • Preferred Skills and Abilities: 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

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