Risk Analyst jobs in West Hartford, CT

Stop Loss Claims Auditor

Job Summary

This position is responsible for examining, auditing and rendering a decision concerning liability of claims made under the Medical Stop Loss policies that the Company has issued to existing clients. Make recommendations and decisions concerning the validity of claims presented, to reimburse, reject or secure additional information until that decision can be made.

Primary Responsibilities

• Audit specific claims for assigned clients.
• Review and approve Plan Documents
• Audit and process claim reimbursements on behalf of the Carrier/Re-Insurer
• Verify that claims are paid in accordance with the Plan Document and Stop Loss Policy
• Review all requests for reimbursement:
• Verify participant and dependent eligibility
• Maintain accurate and detailed information for each file
• Review high cost claims relative to financial and coding accuracy and coordination with Cost Containment programs
• Maintain and exceed targeted claims accuracy standards, Financial 99% and Technical of 97% or greater
• Meet and exceed targeted turnaround time for all submissions and pending claims
• Recover overpaid claims through refund request
• Maintain positive and professional working relationship with peers and clients
• Complete, track and follow up for the TPA approval process
• Cross training with the rating team, as time warrants, the Claims team takes precedent

Technical Skills

• Basic computer skills using MS Office (Outlook, Excel, MS Word)
• Intermediate level experience performing data entry functions

Experience/Skills Needed

• At least 1 year experience with examining and auditing medical stop loss specific claims along with at least 3 years or more of claims processing
• Claims experience of Stop Loss claims or first dollar medical claims
• Knowledge of Plan Documents, Stop Loss Policies and reinsurance contracts
• Knowledge of Medical Terminology (ICD10, HCPCS and CPT4 codes)
• Excellent interpersonal, oral and written communication skills
• Telephone Etiquette
• Ability to work independently as well as with a team
• Must be detailed oriented
• Good organization and time management skills

Job Type: Full-time

Pay: From $52,000.00 per year

Benefits:

• 401(k)
• 401(k) 6% Match
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Matching gift program
• Paid time off
• Parental leave
• Prescription drug insurance
• Professional development assistance
• Referral program
• Tuition reimbursement
• Vision insurance
• Work from home

Schedule:

• Monday to Friday
• Overtime

Work setting:

• Hybrid work
• Office

Experience:

• Stop loss claims processing: 1 year (Preferred)

Ability to Relocate:

• South Windsor, CT 06074: Relocate before starting work (Preferred)

Work Location: Hybrid remote in South Windsor, CT 06074