Medical Stop Loss Adjuster

Job Description

We are looking for a dynamic candidate to aid Medical insurance customers (including administrators, MGUS, brokers) by confirming eligibility, determining insurance coverage, examining and resolving medical stop loss claims, documenting actions, maintaining quality customer service, ensuring compliance.

RESPONSIBILITIES:

• Works directly with the SR. Claims Analyst
• Works closely with Policy issuance and accounting departments
• Process/review 50% notifications
• Establishes proof of loss by reviewing medical documentation presented, requesting additional information from sources such as (administrator, broker, hospital, physician etc.)
• Adjudicates claims in medical stop loss system (ESL) and or (UGAN) approving, denying based on compliance with SPD and Stop loss policy.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
• Knowledge of CPT/HCPC, Revenue and ICD9 to ICD10 coding procedures and guidelines
• Prepares standard and ad hoc reports
• Reports to client regarding reimbursements and in turn forwards to accounting department for reimbursement
• Maintains quality client service by responding timely and accurately to client inquiries
• Maintaining client expected turn-around time
• Ability to communicate effectively with others
• Performs other duties as assigned

KNOWLEDGE AND SKILLS REQUIRED:

• A minimum of two (2) years medical stop loss claims processing or at least 5 years processing claims in a TPA – like setting.
• Strong written and verbal communication skills.
• Working knowledge of David Young (ESL System) and or Kevin Ugan system.
• Flexibility to handle multiple priorities while maintaining high level of professionalism.
• Must be able to work well independently or in a team environment.
• Proficiency using Microsoft office products

Job Type: Full-time

Experience:

• Stop Loss Claims: 1 year (Preferred)
• David Young (ESL System) and/or Kevin Ugan system: 1 year (Preferred)

Benefits offered:

• Paid time off
• Health insurance
• Dental insurance
• Other types of insurance
• Retirement benefits or accounts
• Education assistance or tuition reimbursement