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Seasonal Senior Claims Auditor Consultant — Pennsylvania Remote
Oversee complex Employer Stop Loss claims for One80 Intermediaries, from adjudication and reserve recommendations to audit and resolution. The role focuses on high-cost medical claims, including transplants, oncology, catastrophic conditions, and specialty drugs.
Tavsif
- Oversee and adjudicate complex Employer Stop Loss claims within assigned authority and under policy and contract terms.
- Interpret Stop Loss policies, certificates, plan documents, eligibility rules, deductibles, exclusions, reimbursement terms, and other contract provisions to determine claim eligibility and payment.
- Review high-value, complex, and unusual claims involving major medical expenses, transplants, oncology, catastrophic conditions, specialty drugs, and other costly services.
- Analyze claims data, medical records, eligibility details, provider records, invoices, and supporting documents to verify claim accuracy and reimbursement.
- Check claim adjudication for eligibility, deductibles, exclusions, benefits, payment calculations, and correct application of policy terms.
- Manage large-loss claims and prepare reports, analysis, recommendations, and escalations for the Vice President of Claims and other stakeholders.
- Assess and recommend reserves for large and complex claims using available information, expected liability, policy provisions, and reserving guidelines.
- Track large claims through their lifecycle and update reserves, claim estimates, and management reports.
- Audit claims before and after payment to find payment inaccuracies, processing errors, documentation gaps, and potential recoveries or corrections.
- Identify patterns, recurring errors, system problems, and process gaps that affect claim accuracy or financial performance, and recommend corrective steps.
- Coordinate with TPAs and external claims administrators to resolve complex issues, verify claim information, and maintain contract and administrative compliance.
- Handle inquiries and escalated claim matters from brokers, TPAs, plan sponsors, Underwriting, reinsurers, and other stakeholders.
Talablar
- Bachelor’s degree.
- At least seven years of progressive claims experience, including substantial experience in Employer Stop Loss, medical claims, health benefits, or a related insurance setting.
- Experience handling complex, high-value medical claims.
- Experience auditing and adjudicating claims, reviewing payments, and analyzing claims.
- Experience interpreting insurance contracts, plan documents, and claims provisions.
- Experience managing large-loss claims and recommending reserves.
Imtiyozlar
- Medical and prescription, dental, vision, life, and disability insurance
- Employee stock purchase plan, 401(k), student loan assistance, and tuition reimbursement
- Free mental health and enhanced advocacy services
- Paid time off
- Holidays
- Preferred partner discounts