POSITION SUMMARY
The Stop Loss Claim Specialist is responsible for preparing and filing medical stop loss claims for reimbursement with stop loss carriers for individual stop loss (specific) coverage. Additional duties include following up with the various carriers to ensure reimbursements are received in time and in full. Further responsibilities include the appeals of denied and reduced claim reimbursements, along with retaining the appropriate documentation needed to support the reimbursement request.
ESSENTIAL FUNCTIONS
- Compile and submit claim reports and the necessary documentation to file a stop loss claim.
- Frequently monitor the status of claims assigned and follow up with stop loss carriers.
- Strong ability to answer questions and requests from stop loss carriers for additional information promptly and with thorough information in support of claim reimbursement.
- Communicate with other internal departments to resolve claim issues.
- Prepare both the initial, subsequent, and year end claim filings upon reconciliation of the claim activity.
- Ability to manage time to file advanced funding, high dollar and renewal claim submissions per contract stipulations and department metrics.
- Appeal the denials or reduction of reimbursements by the stop loss carrier.
- Understand stop loss policy provisions, as well as group plan documentation in support of claim reimbursements.
- Ability to adapt to new concepts and systems.
- Other duties as assigned.
EDUCATION
- High School diploma or equivalent required.
- Some college or equivalent work experience preferred.
EXPERIENCE AND SKILLS
- 1 to 2 years of claims experience in a self funded environment
- Have a thorough knowledge of Stop Loss terminologies, concepts, and catastrophic claim handling
- Ability to interpret Stop Loss contracts and Client summary Plan Descriptions (SPD).
- Stop loss filing experience preferred
- Accounting or Finance background a plus.
- Proficient with Microsoft Office Suite, specifically with Microsoft Excel.
- Strong analytical and problem solving skills.
- Excellent verbal and written communication skills.
- Demonstrated elevated level of organizational skills and superior attention to detail.
- Excellent time management skills with a proven ability to meet deadlines.
- Demonstrated ability in developing and maintaining positive relationships with team members, internal departments, various brokers, reinsurance carriers, and clients.
POSITION COMPETENCIES
- Accountability
- Communication
- Customer Service Orientation
- Functional/Technical Skills
- Quality Focus
- Time and Task Management
PHYSICAL DEMANDS
- This is a standard desk role requiring extended sitting and computer work.
WORK ENVIRONMENT
- Remote
Here at Allied, we believe that great talent can thrive from anywhere. Our remote friendly culture offers flexibility and the comfort of working from home, while also ensuring you are set up for success. To support a smooth and efficient remote work experience, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 100Mbps download/25Mbps upload. Reliable internet service is essential for staying connected and productive.
The company has reviewed this job description to ensure that essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills, and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.
Compensation is not limited to base salary. Allied values our Total Rewards, and offers a competitive Benefit Package including, but not limited to, Medical, Dental, Vision, Life and Disability Insurance, Generous Paid Time Off, Tuition Reimbursement, EAP, and a Technology Stipend.
Allied reserves the right to amend, change, alter, and revise, pay ranges and benefits offerings at any time. All applicants acknowledge that by applying to the position you understand that the specific pay range is contingent upon meeting the qualification and requirements of the role, and for the successful completion of the interview selection and process. It is at the Company's discretion to determine what pay is provided to a candidate within the range associated with the role.
Skills Required
- High school diploma or equivalent
- 1 to 2 years of claims experience in a self-funded environment
- Thorough knowledge of stop loss terminology, concepts, and catastrophic claim handling
- Ability to interpret stop loss contracts and Client Summary Plan Descriptions
- Proficiency with Microsoft Office Suite, specifically Microsoft Excel
- Strong analytical and problem-solving skills
- Excellent verbal and written communication skills
- Strong organizational, attention-to-detail, and time-management skills
- Ability to meet deadlines and maintain positive relationships with internal and external stakeholders
- Some college or equivalent work experience
- Stop loss filing experience
- Accounting or finance background
What We Do
Allied is a national healthcare solutions company that works with organizations who choose to take control of their healthcare. We customize employer self-insurance benefits to align with individual choice and organizational need while integrating medical management innovations and cost-control strategies. With healthcare designed for people, employers never have to choose between price and the best-fit insurance products to protect employees and their families. Allied’s philosophy is to create a culture of health for our member organizations and their employees beyond simple, medical health. We integrate administrative services, care solutions and analytics to achieve better clinical, behavioral and social patient outcomes. Allied’s programs and benefit services are designed and structured to infuse value on every front – for employers and HR departments, for plan members and their families, for healthcare providers, and for us. We’re in this together, committed to your future.
