Stop Loss Claims Auditor

Saved job description

Company Details

Berkley Accident and Health  is a risk management company that designs innovative solutions to address the unique challenges of each client. With our entrepreneurial culture and a strong emphasis on analytics, we can help employers better manage their risk. We offer a broad range of products, including employer stop loss, benefit captives, provider stop loss, HMO reinsurance, and specialty accident. The key to Berkley’s success is our nimble approach to risk – our ability to quickly understand, think through, and devise a plan that addresses each client’s challenges, coupled with the strong backing of a Fortune 500 company. Our parent company,  W. R. Berkley Corporation , is one of the largest and best managed property/casualty insurers in the United States.

#LI-AV1 #LI-REMOTE

The Company is an equal employment opportunity employer.  

Responsibilities

Shape High-Dollar Stop Loss Claim Decisions That Matter  

Are you an experienced Stop Loss Claims professional who thrives on analyzing complex medical claims, interpreting contract language, and making informed reimbursement decisions?

As a Stop Loss Claims Auditor (a.k.a. "Claims Analyst"), you'll join a highly respected team where your contribution will directly impact claim outcomes, customer experience, and business results.  You'll perform quality review and evaluation of all claim submissions received and logged into our claims system to determine whether the amount requested is eligible for reimbursement.

This position can either be fully remote (if not within commutable distance to the office) or based in one of our offices:

Hamilton Square, NJ

West Hartford, CT

Marlborough, MA

Harleysville, PA

We offer hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.

What you can expect:

Culture of innovation, teamwork, supportive colleagues and leaders willing to invest in talent

Internal mobility opportunities 

Visibility to senior leaders and partnership with cross functional teams

Opportunity to impact change

Benefits – competitive compensation, paid time off, comprehensive wellness benefits and programs, employer funded health savings account, profit sharing, 401k, paid parental leave, employee stock purchase plan, tuition assistance and professional continuing education

We'll count on you to:

Process an average of 5 to 7 claims per day

Maintain a processing accuracy of 99% or better

Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim

Review and adjudicate claims within approved authority limits

Maintain assigned claim block and assist other team members while meeting departmental guidelines

Document rationale of claim decisions based on review of the contractual provisions, plan specifications and the analysis of medical records, etc.

Elevate issues to next level of supervision, as appropriate

Other duties as assigned

Qualifications

What you need to have:

3-5+ years stop loss claims experience

Prior experience handling first dollar payer insurance (medical healthcare claims)

Experience with medical billing practices, CPT codes, revenue codes, and/or universal billing

Ability to use mathematics to adjudicate claims

Detail oriented with a high degree of accuracy and ability to multitask

Strong problem solving, decision-making, reporting and analytical skills

Must possess good judgment and work effectively with internal business areas, peers and co-workers

Proficiency with Microsoft Excel and Microsoft Office applications

High School Diploma

What makes you stand out:

Prior experience handling stop loss claims at the reinsurance level (medical healthcare claims)

Ability to work independently, prioritize, organize and assign own work to meet deadlines

Ability to accept changing priorities with a minimum of disruption

Additional Company Details

We do not accept any unsolicited resumes from external recruiting firms. Only solicited resumes/candidate profiles that are submitted by a Berkley Preferred Agency Partner that have been requested by Berkley Internal Recruiting to engage in a particular search will be subject to the payment of Agency fees as defined in the formal agency agreement. Any unsolicited resumes/candidate profiles are not subject to payment of the agency fees. The company offers a competitive compensation plan and robust benefits package for full time regular employees including: • Base Salary Range: $70,000 - $80,000 • Benefits include: Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and generous profit-sharing plan The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

Sponsorship Details

Sponsorship not Offered for this Role