Talent.com
serp_jobs.error_messages.no_longer_accepting
Senior Stop Loss Claims Analyst / HNAS (Nashville)

Senior Stop Loss Claims Analyst / HNAS (Nashville)

Tennessee StaffingNashville, TN, US
job_description.job_card.variable_hours_ago
serp_jobs.job_preview.job_type
  • serp_jobs.job_card.part_time
job_description.job_card.job_description

Job Summary

This job reviews, evaluates, and processes various Stop Loss (Excess Risk and Reinsurance) claims in accordance with established turnaround and quality standards. Responsible for building positive client relationships, providing education, and analyzing client claim losses as well as current issues regarding client activities; disseminates necessary information to the management. Follows up on pended claims in accordance with department standards.

Essential Responsibilities

  • Processes daily incoming Stop Loss claims including initial entry claims or subsequent claims as needed; provides counseling to clients and assists with client service programs.
  • Evaluates various claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients for compliance with the following : underlying policy provisions, federal and state regulatory guidelines, and industry standards.
  • Monitors, reviews and analyzes various complex potential claims with emphasis on controlling losses through effective managed care. This includes following a departmental claim checklist to ensure eligibility is met, the payment reimbursement request is accurate by auditing the claim for duplicate line-item charges and determining if all information is available to finalize the payment request. Refers the claim to the cost containment and RxOps departments for review of high dollar charges if applicable.
  • Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre-determined dollar threshold. Completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers utilizing the appropriate application and / or template.
  • Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary. Identifies issues which can be used to educate / train internal staff, streamline, and improve processes and update documentation.
  • Assists leadership with performing client performance evaluations to assess the accuracy of client reports submitted to the organization, efficiency of claim operations, and adequacy of systems and procedures.
  • Approves claim payments on behalf of multiple clients and provides client counseling and support services. Assists in the client service programs including revising and establishing procedures, protocols and ensuring client satisfaction with the organization.
  • Maintains accurate claim records.
  • Other duties as assigned or requested.

Education

Required : High School Diploma / GED

Substitutions : None

Preferred : Bachelor's degree

Experience

Required : 5 years of relevant, progressive experience in health insurance claims; 3 years of prior experience processing 1st dollar health insurance claims; 3 years of experience with medical terminology

Preferred : 3 years of experience in a Stop Loss Claims Analyst role.

Skills

Ability to communicate concise accurate information effectively. Organizational skills. Ability to manage time effectively. Ability to work independently. Problem solving and analytical skills.

Language (Other than English) : None

Travel Requirement : 0% - 25%

Physical, Mental Demands and Working Conditions

Position Type : Office-based Teaches / trains others regularly Occasionally Travel regularly from the office to various work sites or from site-to-site Rarely Works primarily out-of-the office selling products / services (sales employees) Never

Physical work site required : Yes

Lifting : up to 10 pounds Constantly Lifting : 10 to 25 pounds Occasionally Lifting : 25 to 50 pounds Rarely

Disclaimer : The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum : $22.71 Pay Range Maximum : $35.18 Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

serp_jobs.job_alerts.create_a_job

Senior Stop Loss • Nashville, TN, US

Job_description.internal_linking.related_jobs
Claim Support Specialist

Claim Support Specialist

SeekOne Roofing CompanyNashville, TN, USA
serp_jobs.job_card.full_time
serp_jobs.filters_job_card.quick_apply
Are you ready to make an impact in the roofing and insurance industry while working with a company that values your skills and contributions?. This position offers stability, growth opportunities, a...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Loss Prevention Safety Associate II

Loss Prevention Safety Associate II

TJXBrentwood, TN, US
serp_jobs.job_card.full_time
At TJX Companies, every day brings new opportunities for growth, exploration, and achievement.You'll be part of our vibrant team that embraces diversity, fosters collaboration, and prioritizes your...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Compliance Lead for Stop Loss Insurance

Compliance Lead for Stop Loss Insurance

VirtualVocationsNashville, Tennessee, United States
serp_jobs.job_card.full_time
A company is looking for a Compliance Lead, Stop Loss Insurance.Key Responsibilities Manage compliance for agent / agency appointment, vetting, and licensing Maintain policy forms in compliance wi...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
Loan Sales Specialist - Nashville South

Loan Sales Specialist - Nashville South

OneMain FinancialNashville, TN, United States
serp_jobs.job_card.full_time
At OneMain, Loan Sales Specialists empower customers by listening to their needs and providing access to friendly, fast, and affordable financing for life’s expenses. In this role, our team members ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Claims Analyst - US

Claims Analyst - US

DXC TechnologyNashville, TN, US
serp_jobs.job_card.full_time
Follows procedures to process death claim transactions by corresponding with agents, beneficiaries, and other departments regarding policies. Willingness to learn new payment processes and / or other ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Insurance Loss Control Surveyor

Insurance Loss Control Surveyor

Davies Risk ServicesMurfreesboro, TN, US
serp_jobs.job_card.full_time
Seeking Independent Contractors to Perform Insurance Property Inspections.Davies Risk Services is looking for independent contractors to perform insurance property inspections.This is a great oppor...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Claims and Safety Administrator (Nashville)

Claims and Safety Administrator (Nashville)

Enterprise SolutionsNashville, TN, US
serp_jobs.job_card.part_time
Claims Specialist to manage our company's risk and claims program.This critical role is the central point of contact for the end-to-end management of all corporate insurance claims, including worke...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Loss Prevention Clerk

Loss Prevention Clerk

Costco Wholesale CorporationMurfreesboro, TN, US
serp_jobs.job_card.full_time
Position Summary : Protects company assets from internal and external theft.Observes and reports potential safety and security hazards. For additional information about pay ranges, we offer a compreh...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Loss Control Contractor

Loss Control Contractor

TranStar Technical ServicesNashville, TN, US
serp_jobs.job_card.full_time
Commercial Loss Control Inspections Nashville, TN.TranStar Technical Services is a dynamic, growing company in the southeast and we are always on the lookout for qualified candidates to enhance our...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Analyst Nashville, TN (Onsite), 12+ Months Contract

Analyst Nashville, TN (Onsite), 12+ Months Contract

StaffingNashville, TN, US
serp_jobs.job_card.temporary
Locations : Nashville, TN (Onsite) Duration : 12 Months Contract Local to TN candidates only.Summary : Under general supervision, is responsible for regulatory boards administrative work of average di...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Claims Consultant

Claims Consultant

AldevraNashville, TN, US
serp_jobs.job_card.full_time
Business Development and Staffing Manager.Nashville, TN (position is subject to change).Aldevra is currently seeking a qualified Claims Consultant to support the US Army Corps of Engineers (USACE) ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Compensation Analyst

Compensation Analyst

Cracker Barrel Old Country StoreLebanon, TN, US
serp_jobs.job_card.full_time
They say you are the company you keep - and at Cracker Barrel, we take that seriously.At the Store Support Center, we're in the business of serving those who serve our guests.Whether you're designi...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
Senior Catastrophe Risk Analyst

Senior Catastrophe Risk Analyst

Ryan Specialty GroupUSA, Tennessee, Nashville
serp_jobs.job_card.full_time
The Senior Catastrophe Risk Analyst role involves critical assessment and management of the company's exposure to natural and man-made catastrophes. The Senior Catastrophe Risk Analyst analyzes data...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Temp Insurance Claims Specialist

Temp Insurance Claims Specialist

Nashville CARESNashville, TN, US
serp_jobs.job_card.full_time
Now Hiring! Temp Insurance Claims Specialist.Process insurance-related documentation accurately and timely and consistent with program guidelines. Verify vendor and payment details with insurance co...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_1_day
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Field Claims Investigator

Field Claims Investigator

Phoenix Loss controlFranklin, TN, US
serp_jobs.job_card.part_time
Workplace Type : Hybrid (50% remote, 50% fieldwork).Compensation : $25 / hr plus $.Phoenix Loss Control (PLC) is a US-based business services provider in the cable, t...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
  • serp_jobs.job_card.new
Shh... It’s a Quiet Shift (But We’re Still Hiring)

Shh... It’s a Quiet Shift (But We’re Still Hiring)

Southern Health PartnersPleasant View, TN, United States
serp_jobs.job_card.full_time
Calling all night owls with scrubs!.If you shine after sunset and prefer a shift that’s calm, focused, and far from the chaos of day shift drama—this is your moment. Competitive Pay + Night Shift Di...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_hours
  • serp_jobs.job_card.promoted
CDL A Truck Driver

CDL A Truck Driver

Venture ExpressWartrace, TN, US
serp_jobs.job_card.full_time
Local & Regional Driving Jobs.Local pay - up to $1,500 / week Regional pay - up to $1,800 / week.Multiple Home Times Available to Fit Your Schedule. Company Paid Life Insurance & 401(k).Referral...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_30
  • serp_jobs.job_card.promoted
Senior Business Analyst - Claims

Senior Business Analyst - Claims

VirtualVocationsMurfreesboro, Tennessee, United States
serp_jobs.job_card.full_time
A company is looking for a Senior Business Analyst - Claims.Key Responsibilities Coordinate the business analyst team's activities on IT projects and mentor newer team members Facilitate client ...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Loss Prevention Supervisor

Loss Prevention Supervisor

Kohl'sMurfreesboro, TN, US
serp_jobs.job_card.full_time
As Loss Prevention Supervisor you will improve company profitability by executing company programs around external theft deterrence, internal investigations and operational shortage.You will increa...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days
  • serp_jobs.job_card.promoted
Senior Product Analyst (Nashville)

Senior Product Analyst (Nashville)

HCA HealthcareNashville, TN, US
serp_jobs.job_card.part_time
Product Analyst Consulting Level.The Product Analyst / Consulting-Level reviews, analyzes, and evaluates information technology systems operations. In this role you will be part of a team that deli...serp_jobs.internal_linking.show_moreserp_jobs.last_updated.last_updated_variable_days