Senior Stop Loss Claims Analyst

Company :

HM Insurance Group

Job Description : 

JOB SUMMARY

This job reviews, evaluates, and processes various Excess Risk and Reinsurance Claims.  The incumbent responsible for the conversation of positive client relationships, education, and analysis of client claim losses as well as analysis of current issues regarding client activities with dissemination of this information to the management.

ESSENTIAL RESPONSIBILITIES  

• Display effective communication skills while providing counseling to clients and assisting with client service programs and interacting with internal departments
• Claims Analysis: Process daily incoming Stop Loss claims. Monitor, review and analyze various potential claims with emphasis on controlling losses through effective managed care. Frequent overnight travel nationally to assist Manager with performing client performance evaluations to assess the accuracy of client reports submitted to the Organization, efficiency of claim operations, and adequacy of systems and procedures. Evaluate various claims submitted by Third Party Administrators (TPAs) on behalf of self-funded clients for compliance with the following: underlying policy provisions,  federal and state regulatory guidelines, and industry standards.  
• Client Interaction: Approve claim payments on behalf of multiple clients. Provide client counseling and support services. Assist in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the Organization
• Other duties as assigned or requested.

EDUCATION
 

Required

• High School Diploma/GED

Substitutions

• None

Preferred

•  Bachelor’s Degree

EXPERIENCE

Required

• 5 years of relevant, progressive experience in health insurance claims
• Prior experience processing 1st dollar health insurance claims
• Prior experience with Medical Terminology

Preferred:

• Prior experience in a Stop Loss Claim Analyst  role

SKILLS

• Ability to communicate concise accurate information effectively
• Organizational skills
• Ability to manage time effectively
• Ability to work independently
• Problem Solving and analytical skills

Language (Other than English):

None

Travel Requirement:

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$20.80

Pay Range Maximum:

$37.43

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability. 

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