Stop Loss Specialist

• Analyze and reviews claims for accuracy and completeness to determine eligibility of reimbursement.
• Prepares and maintains reports.
• Responsible for researching, collecting, summarizing, and submitting health insurance claims to stop loss carriers for client reimbursement.
• Strong attention to detail and analytical skills a must.
• The Stop Loss Specialist is in daily contact with team members, providers, clients, brokers, and reinsurance carriers.
• Accurate and timely notifications of Trigger Diagnosis and 50% of specific deductible to stop loss carriers and clients.
• Review pre-authorizations for notification purposes.
• Complies with departmental policies and procedures.
• Files stop loss claims - initial, subsequent and/or final filings, making sure all necessary documentation is included and submitted in a timely manner.
• Develops and maintains relations with various brokers, carriers and clients.
• Follow-up on any initial filings at 2 weeks and subsequent filings every 3 days including documentation on specific stop loss spreadsheet as to follow-up date and why reimbursement has not been received.
• Other duties as assigned.

• Have a thorough knowledge of stop loss claim handling, coding structures (CPT, HCPCS, UB/Revenue codes, ICD 9/10 etc.)
• Ability to read and understand Reinsurance contracts and Summary Plan Descriptions (SPD).
• Have good organizational skills and is able to manage time and resources effectively and efficiently.
• Exhibits an attention to detail and strong work ethic.
• Ability to perform arithmetic calculations.
• Knowledge of Coordination of Benefits (COB).
  

The statements above describe the general  requirements of the job but are not intended as an all-inclusive listing  of duties that may be required of the individual in this position from  time to time.