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Job Type: Full-time
Essential Duties and Responsibilities
Responsible for the handling and oversight of the Claims Adjudication Process, which includes, but it not limited to, the following:
• Review and adjudicate Monthly Aggregate Accommodation Requests and Final Aggregate Stop Loss Claim Submissions (collectively known as “Aggregate Claims”), taking into account all applicable Stop Loss Policy Provisions, Plan Document Provisions, and internal Claims processing protocols.
• Handle Over-Authority Review Requests received from Claims Staff and approve Aggregate Claims for payment within assigned authority, if applicable, or explain to the Claims Staff member why an Aggregate Claim may not be ready/eligible for a benefit payment.
• If the Over-Authority Review exceeds the Stop Loss Claims Manager’s Authority, then the Manager must review and approve the Aggregate Claim, then forward it to the Director, Claims Operations for further review and approval.
• Responsible for submitting Over-Authority Review Requests to the applicable Stop Loss Carrier for final approval, if the benefit amount due on an Aggregate Claim exceeds the dollar threshold set by the applicable Carrier and it’s been approved internally.
• Consult with the Director, Claims Operations and the Vice President, Claims Operations, along with other departments (e.g., Underwriting, Administration, etc.) to handle/resolve complex Aggregate Claims and/or potential Aggregate Claim issues.
• Updates Claims system and internal Claims files/folders and ensures that the Claims Staff is updating the system and files/folders appropriately, as well.
• Assists the Director, Claims Operations and the Vice President, Claims Operations with the development of new Claims Policies & Procedures (“P&Ps”), as well as the updating and maintenance of the Claims Manual/ P&Ps to support a highly functional infrastructure within Claims Operations.
• Respond to inquiries from the Third-Party Administrators (“TPAs”) and Policyholders to answer questions and to provide status of the Aggregate Claims in question.
• Responsible for completing the Quality Review (“QR”) Process to ensure claims are being handled and adjudicated correctly, based on the Stop Loss Policy provisions, the terms/provisions of the Plan Documents/ SPDs, and the standard Claims Operations’ P&Ps.
Qualifications for the Stop Loss Claims Manager include:
• Minimum of 5 years of experience with handling medical claims processing/adjudication, which includes first-dollar medical claims, medical stop loss claims, excess loss claims, and/or reinsurance claims.
• Minimum of 3 years of Managerial/Supervisory experience or bachelor’s degree.
• Experience with third party administration, stop loss, excess loss, and/or reinsurance is preferred.
• Must have knowledge of CPT, ICD-10, and HCPCS codes, along with knowledge of medical claim practices. Additional knowledge of medical billing and coding practices preferred.
• Strong analytical skills/abilities, along with having keen critical decision-making and problem-solving skills, are a must.
• Highly proficient in Microsoft Office applications, especially Outlook, Excel, and Word.
• Excellent verbal and written communication skills, along with sound organizational skills, and effective customer service abilities are a must.
• Must be able to handle difficult and stressful situations, work in a fast-paced environment, manage effectively, and maintain acceptable productivity, while maintaining a high level of quality.