Remote – Stop Loss Auditor
A Connecticut based Medical Insurance company is seeking an experienced Stop Loss Auditor to join a fully remote team supporting medical stop loss insurance operations. This role focuses on auditing high-cost medical claims, evaluating liability under stop loss policies, and ensuring accurate and compliant reimbursement.
Compensation: $65,000-75,000 base
Responsibilities
- Audit medical stop loss claims for assigned clients
- Review and approve Plan Documents to ensure compliance
- Evaluate reimbursement requests and determine claim validity
- Verify claims are paid according to Plan Documents and Stop Loss policies
- Confirm participant and dependent eligibility
- Review high-cost claims for financial accuracy, coding accuracy, and cost containment coordination
- Process claim reimbursements on behalf of carriers/reinsurers
- Maintain accurate and detailed claim documentation
- Meet established accuracy and turnaround time standards
- Identify and recover overpaid claims through refund requests
- Partner with TPAs throughout the approval process
- Maintain professional relationships with internal teams and external clients
- Participate in cross-training opportunities as business needs allow
Qualifications
- 3+ years of medical stop loss insurance experience (required)
- Experience auditing stop loss or first-dollar medical claims
- Strong knowledge of: Plan Documents and Stop Loss policies, Reinsurance contracts, Medical terminology and coding (ICD-10, HCPCS, CPT-4)
- Ability to work independently in a remote environment while collaborating with a team
This is a fully remote opportunity! For immediate consideration, please reach out directly to Kelly Lucey at [email protected] with a copy of your resume.
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