Stop Loss Claims Supervisor

The Stop Loss Claims Supervisor shall assist the Stop Loss Claims Manager, Director of Claims Operations, and the Vice President of Claims Operations with the handling and managing of the Stop Loss Claim Adjudication Process, along with assorted Claims support functions. The Stop Loss Claims Supervisor assists the aforementioned Claims Leadership with the development and oversight of the Claims Staff to improve operational efficiency and to maintain a smooth process workflow.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Responsible for assisting the Claims Leadership with the handling and oversight of the Claims Adjudication Process, which includes, but it not limited to, the following:
• Review and adjudicate Monthly Aggregate Accommodation Requests and Final Aggregate Stop Loss Claim Submissions (collectively known as "Aggregate Claims"), taking into account all applicable Stop Loss Policy Provisions, Plan Document Provisions, and internal Claims processing protocols. Handle Over-Authority Review Requests received from Claims Staff and approve Aggregate Claims for payment within assigned authority, if applicable, or explain to the Claims Staff member why an Aggregate Claim may not be ready/eligible for a benefit payment.
• If the Over-Authority Review exceeds the Stop Loss Claims Supervisor's Authority, then the Supervisor must review and approve the Aggregate Claim, then forward it to the Stop Loss Claims Manager for further review and approval.
• Responsible for submitting Over-Authority Review Requests to the applicable Stop Loss Carrier for final approval, if the benefit amount due on an Aggregate Claim exceeds the dollar threshold set by the applicable Carrier and it's been approved internally.
• Consult with the Stop Loss Claims Manager, the Director of Claims Operations and the Vice President of Claims Operations, along with other departments (e.g., Underwriting, Administration, etc.) to handle/resolve complex Aggregate Claims and/or potential Aggregate Claim issues.
• Updates Claims system and internal Claims files/folders and ensures that the Claims Staff is updating the system and files/folders appropriately, as well.
• Assists the Claims Leadership Team with the development of new Claims Policies & Procedures ("P&Ps"), as well as the updating and maintenance of the Claims Manual/P&Ps to support a highly functional infrastructure within Claims Operations.
• Respond to inquiries from the Third-Party Administrators ("TPAs") and Policyholders to answer questions and to provide status of the Aggregate Claims in question.
• Responsible for training new Claims Specialists and providing update/refresher training to existing Claims Specialists and Senior Claims Specialists, as directed by the Claims Leadership Team
• Responsible for completing the Quality Review ("QR") Process to ensure claims are being handled and adjudicated correctly, based on the Stop Loss Policy provisions, the terms/provisions of the Plan Documents/SPDs, and the standard Claims Operations' P&Ps.

Qualifications for the Stop Loss Claims Supervisor include:

• Minimum of 5 years of experience with handling medical claims processing/adjudication, which includes first-dollar medical claims, medical stop loss claims, excess loss claims, and/or reinsurance claims.
• Minimum of 1 year of Managerial/Supervisory experience or bachelor's degree.
• Experience with third party administration, stop loss, excess loss, and/or reinsurance is preferred.
• Must have knowledge of CPT, ICD-10, and HCPCS codes, along with knowledge of medical claim practices. Additional knowledge of medical billing and coding practices preferred.
• Strong analytical skills/abilities, along with having keen critical decision-making and problem-solving skills, are a must.
• Highly proficient in Microsoft Office applications, especially Outlook, Excel, and Word.
• Excellent verbal and written communication skills, along with sound organizational skills, and effective customer service abilities are a must.
• Must be able to handle difficult and stressful situations, work in a fast-paced environment, manage effectively, and maintain acceptable productivity, while maintaining a high level of quality.

Current Openings for Stop Loss Claims Supervisor Jobs at Health in Tech