Job Description: Stop Loss Claims Auditor

Location: Remote or Hybrid (U.S.)
Industry: Insurance / Self‑Funded Health Plans / Stop Loss

About the Role

My client leading provider of underwriting, analytical, and claims management services is seeking an experienced Stop Loss Claims Auditor to join its growing team. This role plays a critical part in ensuring accuracy, compliance, and financial integrity across high‑cost medical claims within self‑funded health plans and stop loss programs.

The Stop Loss Claims Auditor will evaluate claim adjudication practices, validate eligibility and benefit application, ensure alignment with stop loss policy provisions, and collaborate with internal and external partners to improve claims quality and reduce financial risk.

Key Responsibilities

Claims Audit & Analysis

• Conduct comprehensive audits of medical, pharmacy, and disability claims for stop loss reimbursement eligibility.
• Review large‑dollar and catastrophic claims for accuracy, completeness, and compliance with policy terms.
• Validate claim coding, billing methodologies, pricing, and provider contract application (PPO, RBP, etc.).
• Analyze underlying claim drivers, trends, and anomalies to identify potential errors or cost‑containment opportunities.

Policy & Compliance Review

• Interpret stop loss policies, plan documents (SPDs), administrative services agreements, and vendor contracts to determine proper claim handling.
• Ensure claims meet ERISA, HIPAA, and state regulatory requirements.
• Evaluate network repricing accuracy and ensure proper application of negotiated discounts.

Audit Reporting & Communication

• Prepare detailed audit findings, summaries, and financial impact assessments for internal teams and clients.
• Present audit conclusions and recommendations with clarity, accuracy, and professionalism.
• Assist underwriting, claims, and actuarial teams by providing audit‑derived insights related to risk evaluation and claims trends.

Process Improvement

• Identify systemic issues, process gaps, and operational inefficiencies in claims handling.
• Partner with TPA partners, carriers, and internal stakeholders to implement corrective actions.
• Develop and maintain audit tools, methodologies, and best‑practice guidelines.

Qualifications

Required

• 3-5+ years of experience in stop loss claims, medical claims auditing, health plan administration, or related roles.
• Deep understanding of self‑funded health plans, stop loss coverage, and claim adjudication practices.
• Strong knowledge of medical coding (ICD‑10, CPT, HCPCS) and billing methodologies (UB‑04/1500).
• Ability to interpret plan documents, stop loss policies, and provider contracts.
• Excellent analytical, investigative, and critical‑thinking skills.
• High proficiency with Excel, audit tools, and claim platforms.
• Strong written communication skills with the ability to produce clear, defensible audit reports.

Preferred

• Experience with TPA operations, carrier recovery processes, or medical bill review.
• Familiarity with reference‑based pricing, transplant networks, and specialty cost programs.
• Industry certifications (e.g., CPMA, CPC, CHC, RHIT, CLU, CEBS) a plus.

Competencies

• High attention to detail and accuracy
• Investigative mindset and ability to work independently
• Strong time‑management and organizational skills
• Ability to handle confidential information with discretion
• Collaborative approach with internal teams and external partners

Why Join Us?

• Opportunity to work in a specialized niche of the insurance and self‑funded healthcare industry
• Impact financial outcomes through high‑visibility audit work
• Work with a collaborative, expert‑level team
• Competitive compensation and benefits
• Flexible remote or hybrid work environment