Stop Loss Claims Auditor
Location: Remote
Department: Claims / Underwriting
Employment Type: Full-Time
About the Company:
My client is a leading provider of innovative and customized stop loss insurance solutions. Their mission is to deliver exceptional underwriting and claims services that empower clients to manage risk effectively. Their team is composed of experienced professionals committed to integrity, precision, and excellence in everything we do.
Position Summary:
My client is seeking a detail-oriented and experienced Stop Loss Claims Auditor to join our growing team. This role is responsible for auditing and analyzing stop loss claims to ensure accuracy, compliance with policy provisions, and adherence to industry standards. The ideal candidate will have a strong background in medical claims, stop loss insurance, and auditing practices.
Key Responsibilities:
- Review and audit stop loss claims submitted by third-party administrators (TPAs) and clients for accuracy and compliance with policy terms.
- Analyze large claim submissions, including medical records, billing statements, and supporting documentation.
- Identify discrepancies, overpayments, and potential fraud or abuse.
- Collaborate with underwriting, claims, and legal teams to resolve complex claim issues.
- Provide detailed audit findings and recommendations to internal stakeholders.
- Maintain accurate documentation of audit results and follow-up actions.
- Assist in the development and refinement of audit procedures and best practices.
- Stay current with industry regulations, coding standards (ICD-10, CPT, HCPCS), and emerging trends in healthcare and stop loss insurance.
Qualifications:
- Bachelor's degree in healthcare administration, nursing, insurance, or a related field (or equivalent experience).
- Minimum of 3-5 years of experience in stop loss claims auditing, medical claims review, or a related field.
- Strong knowledge of stop loss insurance, medical terminology, and healthcare billing practices.
- Familiarity with regulatory requirements (ERISA, HIPAA, etc.).
- Excellent analytical, organizational, and communication skills.
- Proficiency in Microsoft Office Suite and claims management systems.
Preferred Qualifications:
- Experience working with self-funded employer groups and TPAs.
- Knowledge of reinsurance and underwriting processes.
Why Join Us?
- Competitive compensation and benefits package
- Collaborative and supportive team environment
- Opportunities for professional growth and development
- Flexible work arrangements, including remote options
- A mission-driven company with a strong reputation in the stop loss industry
FAQs
Congratulations, we understand that taking the time to apply is a big step. When you apply, your details go directly to the consultant who is sourcing talent. Due to demand, we may not get back to all applicants that have applied. However, we always keep your CV and details on file so when we see similar roles or see skillsets that drive growth in organisations, we will always reach out to discuss opportunities.
Yes. Even if this role isn’t a perfect match, applying allows us to understand your expertise and ambitions, ensuring you're on our radar for the right opportunity when it arises.
We also work in several ways, firstly we advertise our roles available on our site, however, often due to confidentiality we may not post all. We also work with clients who are more focused on skills and understanding what is required to future-proof their business.
That's why we recommend registering your CV so you can be considered for roles that have yet to be created.
Yes, we help with CV and interview preparation. From customised support on how to optimise your CV to interview preparation and compensation negotiations, we advocate for you throughout your next career move.