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About the Role

Audit and authorize reimbursement of specific and/or aggregate medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service.

Responsibilities

• Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier.
• Recognize cost mitigation opportunities.
• Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits.
• Initiate claims investigations and vendor referrals.
• Interpret plan language, and identify experimental services and subrogation opportunities.
• Identify need for follow-up on pended claims and resolution.
• Communicate effectively with carriers, vendors, and management.
• Provide full claims service to both phone and written inquiries.
• Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history.
• Develop new and review old stop loss claim forms.
• Assist with internal auditing of claims auditors, and training of claims auditors.

Requirements

• 6 years of managed care or reinsurance claims experience.

Skills

• Analyzes laws, regulations and contract language.
• Evaluates issues and develops recommendations.
• Handles confidential and sensitive information.
• Investigates assigned claims.
• Proposes claims adjustments and refunds.
• Works claims caseloads.
• Aggregate claims experience.

Location

• Remote

Work Type

• Full-time

Experience Level

• 6 years

Education Level

• Associate's

Salary/Compensations

• $53,320.00 - $101,718.00

Benefits

• Subsidized health plans, dental and vision coverage
• 401k retirement savings plan with company match
• Life Insurance
• Paid Time Off (PTO)
• On-site cafeterias and fitness centers in major locations
• Education Assistance
• Service Recognition
• National discounts to movies, theaters, zoos, theme parks and more

About the Company

• iiSi | Writing Medical Stop Loss Across the Nation – one of BlueCross BlueShield's South Carolina subsidiary companies.
• For more than seven decades we’ve been part of the national landscape, with our roots firmly embedded in the South Carolina community.
• Our A.M. Best rating is A+ (Superior) — making us the only health insurance company in South Carolina with that rating.
• We’re the largest insurance company in South Carolina … and much more.
• We are one of the nation’s leading administrators of government contracts.
• We operate one of the most sophisticated data processing centers in the Southeast.
• We also have a diverse family of subsidiary companies that allows us to build on a variety of business strengths.
• We deliver outstanding service to our customers.
• BlueCross is a strong supporter of our veterans, and many service men and women have joined our ranks.
• We’ve found the dedication, work ethic and job skills that serve well in the military excel in many of our lines of business, and we proudly have veterans filling positions in Human Resources, Information Technology, Customer Service, Operations, General Services and more.
• Through our government contracts, we also have employees serving at Shaw Air Force Base, the Naval Health Clinic in Charleston, the Naval Hospital in Beaufort and in our hometown of Columbia, S.C., at Ft. Jackson.
• If you are a full-time employee in the National Guard or Reserves, we will even cover the difference in your pay if you are called to active duty.

Equal Opportunity

• BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status.
• Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans.
• It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
• We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.
• We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision.
• We are an Equal Opportunity Employer.