Senior Stoploss Claim Auditor

BlueCross BlueShield of South Carolina

Audit and authorize medical stop loss claims for BlueCross BlueShield's subsidiary. Mitigating client claims while ensuring excellent customer service and compliance with regulations.

Posted 5/9/2026full-timeRemote • California • 🇺🇸 United StatesSenior💰 $53,320 - $101,718 per yearWebsite

About the role

Key responsibilities & impact

Audit and authorize reimbursement of specific and/or aggregate 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.

Requirements

What you’ll need

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

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical stop loss claimsclaims adjudicationclaims investigationscost mitigationclaims adjustmentsclaims reportingmanaged care claimsreinsurance claimssubrogationaggregate claims

Soft Skills

customer servicecommunicationanalytical skillsproblem-solvingconfidentialityrecommendation developmenttrainingissue evaluationfollow-upvendor management