Senior Stoploss Claim Auditor

BlueCross BlueShield of South Carolina

Audit and authorize reimbursement of specific medical stop loss claims for BlueCross BlueShield of South Carolina. Effectively mitigate client medical stop loss claims while providing excellent customer service.

Posted 7/2/2026full-timeRemote • Florida • 🇺🇸 United StatesSenior💰 $51,107 - $97,729 per yearWebsite

About the role

Key responsibilities & impact

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

Associate's degree
6 years of managed care or reinsurance claims experience
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

Benefits

Comp & perks

Health insurance
401(k) matching
Flexible work hours
Paid time off
Professional development opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Claims AdjudicationClaims ReportingPlan Language InterpretationSubrogation IdentificationClaims AuditingVendor ReferralsConfidential Information HandlingRecommendations DevelopmentClaims Caseload ManagementRefund Proposals

Soft Skills

Effective CommunicationProblem SolvingAttention to DetailTraining and Mentoring

Certifications

Associate's Degree