Highmark · 3 weeks ago
Senior Stop Loss Claims Analyst - HNAS
Erie-Meadville Area
Full-time
Onsite
Senior Level
$22.71/hr - $35.18/hr
5+ years expHighmark Inc. is a national blended health organization with a mission to create remarkable health experiences. The Senior Stop Loss Claims Analyst is responsible for reviewing, evaluating, and processing Stop Loss claims while building positive client relationships and ensuring compliance with various regulatory guidelines.
Health CareHealth InsuranceInsuranceWellness
Responsibilities
Processes daily incoming Stop Loss claims including initial entry claims or subsequent claims as needed; provides counseling to clients and assists with client service programs
Evaluates various claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients for compliance with the following underlying policy provisions, federal and state regulatory guidelines, and industry standards
Monitors, reviews and analyzes various complex potential claims with emphasis on controlling losses through effective managed care. This includes following a departmental claim checklist to ensure eligibility is met, the payment reimbursement request is accurate by auditing the claim for duplicate line-item charges and determining if all information is available to finalize the payment request. Refers the claim to the cost containment and RxOps departments for review of high dollar charges if applicable
Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre-determined dollar threshold. Completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers utilizing the appropriate application and/or template
Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary. Identifies issues which can be used to educate/train internal staff, streamline, and improve processes and update documentation
Assists leadership with performing client performance evaluations to assess the accuracy of client reports submitted to the organization, efficiency of claim operations, and adequacy of systems and procedures
Approves claim payments on behalf of multiple clients and provides client counseling and support services. Assists in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the organization
Maintains accurate claim records
Other duties as assigned or requested
Qualification
Required
High School Diploma/GED
5 years of relevant, progressive experience in health insurance claims
3 years of prior experience processing 1st dollar health insurance claims
3 years of experience with medical terminology
Ability to communicate concise accurate information effectively
Organizational skills
Ability to manage time effectively
Ability to work independently
Problem Solving and analytical skills
Preferred
Bachelor's degree
3 years of experience in a Stop Loss Claims Analyst role
Company
Highmark
Highmark provides health insurance plans for individuals and businesses.
10001+ employees
H1B Sponsorship
Highmark has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (11)
2024 (7)
2023 (19)
2022 (21)
2021 (18)
2020 (23)
Funding
Current Stage
Late StageTotal Funding
$27.3M2018-04-06Grant· $25M
2014-08-07Grant· $2.3M
Leadership Team
Deborah Rice-Johnson
CEO, Diversified Businesses at Highmark Inc. and Chief Growth Officer
Paul Sikora
CTO Provider Services
Recent News
2025-12-11
Company data provided by crunchbase