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Cambia Health Solutions · 1 day ago

Stop Loss Claims Analyst

United States

Full-time

Remote

Senior Level

$69K/yr - $93K/yr

5+ years exp

Cambia Health Solutions is dedicated to creating a person-focused and economically sustainable health care system. They are seeking a Stop Loss Claims Analyst to adjudicate stop loss claims by developing policies and procedures to ensure consistent claim practices and adherence to regulations.

BiotechnologyHealth CareInformation Technology

Responsibilities

Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims. Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details

Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information

Lead the process to measure, track, and report all aggregate claims

Audit all aggregate claims onsite and off-site when needed based on set dollar threshold. Provide client audit reporting as needed

Manage inventory of claims while ensuring best practices and claim standards are met

Identify new opportunities to track and process claims more efficiently. Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes

Analyze and investigate all claims, request supplementary documentation as necessary, in order to process or reprocess claims in a timely and accurate manner

Qualification

Claims processing experiencePolicy termsClaim reserving knowledgeMedical terminology understandingICD-10/CPT codingAI tools experienceCommunication skills

Required

High School Diploma or GED

5 years of professional claims processing experience or equivalent combination of education and experience

Knowledge of when to utilize legal and clinical resources to comprehend legal and medical terminology in order to make final determinations on whether to approve or further investigate a claim

Possess strong knowledge of Policy and Contract terms, lasering, aggregating deductibles and eligibility to ensure correct processing of all eligible claim reimbursements

Advanced knowledge of claim reserving and settlement

Excellent communication skills for both external and internal customers

Demonstrate understanding of medical terminology and ICD-10/CPT coding

Preferred

Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Benefits

Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.

Annual employer contribution to a health savings account.

Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.

Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).

Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).

Award-winning wellness programs that reward you for participation.

Employee Assistance Fund for those in need.

Commute and parking benefits.