Stop Loss Specialist

Stockton, CA

Job Details

  • 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.

Job Qualifications

  • 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.

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