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Senior Stop Loss Claims Auditor
BlueCross BlueShield of South CarolinaSenior Stop Loss Claims Auditor auditing and adjudicating medical claims for BlueCross BlueShield of South Carolina. Managing reimbursement, investigations, reserves, and claims reporting remotely from Texas.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in auditing and authorizing medical stop loss claims, with a strong focus on analyzing claims, mitigating costs, and providing exceptional customer service. Proficient in interpreting plan language and managing claims investigations while ensuring compliance with regulations.
Highest-signal resume keywords
Medical Stop Loss Claims ManagementClaims Analysis and AdjudicationCustomer Service ExcellenceManaged Care or Reinsurance ExperienceClaims Investigation and Resolution
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AuditingCost Mitigation AnalysisClaims AdjustmentsRegulatory Compliance AnalysisClaims ReportingPlan Language InterpretationSubrogation IdentificationConfidential Information HandlingClaims Caseload ManagementVendor Referral Initiation
Soft Skills
Effective CommunicationProblem SolvingAttention to DetailInterpersonal SkillsTraining and Mentoring
Tools & Technologies
Claims Management SystemReporting Software
Certifications & Qualifications
Associate's Degree
Industry Keywords
Managed CareReinsuranceClaims ProcessingStop Loss InsuranceClaims Investigation
About the role
Key responsibilities & impact- Audit and authorize reimbursement of specific medical stop loss claims
- Mitigate client medical stop loss claims and provide customer service
- Analyze and adjudicate stop loss claims and request appropriate reimbursement from carriers
- Recognize cost mitigation opportunities
- Authorize and release stop loss claims reimbursement checks within authority limits
- Initiate claims investigations and vendor referrals
- Interpret plan language and identify experimental services and subrogation opportunities
- Follow up on pended claims and resolve outstanding issues
- Communicate with carriers, vendors, and management
- Provide claims service for phone and written inquiries
- Generate and maintain claims system reports to adjust reserves and identify pending and backlog claims
- Provide renewal and enrollment/premium history
- Develop new and review existing stop loss claim forms
- Assist with internal auditing and training of claims auditors
Requirements
What you’ll need- Associate's Degree required
- 2 years of job-related work experience may serve as the degree equivalency
- 6 years of managed care or reinsurance claims experience
- Analyze laws, regulations, and contract language
- Evaluate issues and develop recommendations
- Handle confidential and sensitive information
- Investigate assigned claims
- Propose claims adjustments and refunds
- Work 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