Claims Analyst

Position Overview:

The Claims Analyst is responsible for providing assistance to the Claims Manager while ensuring that claims are properly adjudicated in accordance with our Policy and the underlying Plan/Group Documents.

This position will report to the Claims Manager.

Essential Elements

Review, analyze, manage, and adjudicate claims on the Stop Loss and Excess of Loss book of business to determine action to be taken.
Research and resolve claim issues by identifying and analyzing problems and/or risks, and assembling the documentation needed to support the recommendation to resolve the problem.
Maintain applicable logs, files, and company turnaround time standards.
Maintain knowledge of the insurance industry through continuing education.
Other tasks as assigned.

Requirements:

Education and Certifications:

Bachelor’s degree or commensurate experience required
Insurance industry designations preferred

Experience:

Knowledge of current state issues, regulations, and industry trends as it relates to claims required
Demonstrate proficiency with computer software, including Microsoft Office Suite, with advanced skills in Excel required
Knowledge of COB, Medicare, HIPPA, CPT, ICD-10, COBRA, and benefit plan interpretation preferred
Knowledge of medical insurance stop-loss contracts and self-funded plans preferred
Understanding and experience with data analytics preferred
Experience handling large volumes of stop loss claims preferred
Understanding and experience with data analytics preferred

Travel:

Limited travel to Third Party Administrator (TPA) sites.