Stop Loss Analyst

Stop Loss Analyst Job Description

Nashville, TN

Hybrid

Role Summary

The Stop Loss Claims Analysts are a key part of the department’s successful operation. The Stop Loss Claims Analyst is in daily contact with team members, providers, clients, brokers, and reinsurance carriers.

A cheerful, competent and compassionate attitude will directly impact the productivity of the stop loss team and claims department.

This position requires flexibility in duty assignments. Attendance and attitude are key as they can directly impact the satisfaction level of our clients and retention of our accounts.

Daily Role Responsibilities :

• Processes claims accurately, efficiently and within production requirements as well as split claims for stop loss purposes.
• Exhibits an attention to detail and a strong work ethic.
• Exhibits the ability to access and utilize research tools for accurate claims entry.
• Ability to read and understand contracts - Reinsurance contracts and Summary Plan Descriptions (SPD).
• Possesses good organizational skills and can manage time and resources effectively and efficiently.
• Possesses a thorough knowledge of coding structures (CPT, HCPCS, UB / Revenue codes, ICD 9 / 10 etc.)
• Ability to perform arithmetic calculations.
• Knowledgeable of Coordination of Benefits (COB).
• Good understanding of benefits and benefit calculations.
• Ability to handle all types of claims pricing (Network, Medicare, UCR, Reference Based Pricing, negotiations, etc.)
• Performs duties in a HIPAA compliant manner.
• Participates as a team member to ensure the smooth operation of the entire department.
• Maintains guidelines and notes with detail to enable accurate claims examination.
• Maintains Turnaround Time (TAT) guidelines and accuracy goals with filing of Aggregate and Specific stop loss claims.
• Runs both monthly and renewal reports from BI as well as other reports to assist with both Aggregate and Specific stop loss filings.
• Accurate and timely notifications of Trigger Diagnosis and 50% of specific deductible to stop loss carriers.
• Reviews pre-authorizations for notification purposes.
• Files stop loss claims - initial, subsequent and / or final filings, making sure all necessary documentation is included and submitted in a timely manner.
• Reviews accuracy of claims included with reimbursement requests to prevent additional delay once the reinsurance claim has been received by the carrier.
• Mails reimbursement checks to the clients including a cover letter explaining payment.
• Maintenance of stop loss spreadsheets and stop loss files
• Follows-up on any initial filings at 3 weeks and subsequent filings at 2 weeks including documentation on specific stop loss spreadsheet as to follow-up date and why reimbursement has not been received.
• Develops and maintains relationships with the various brokers, carriers and contacts at the clients.
• Responsible for aggregate audits.
• Complies with company policies and procedures as outlined in the Employee Handbook.
• Complies with departmental policies and procedures.
• Assists in training / mentoring of other employees at the Supervisor or Manager’s request to ensure consistency within the stop loss department.
• Demonstrates the ability to complete root cause analysis and develop process improvement plans to present to Management.
• Regular, predictable attendance is required.
• Ability to get along and work effectively with others.
• Performs special projects at the request of Management and, other duties as assigned.

This position could be a good fit if you have :

2-4 years previous health insurance claims experience. Working knowledge of coding structures; claims pricing and claims pricing (Network, Medicare, RBP (Ref.

Based Pricing) structures, CPT, HCPCS, Revenue codes, ICD 9 / 10, etc. experience or certification understanding of claims analyst process and procedures skills.

• Thorough understanding of Self-Funding and Third-Party Administrating concepts.
• Bachelor’s degree preferred or experience in similar role.
• Ability to navigate through and utilize 25+ PC applications efficiently.
• Strong organizational skills, problem solving, and decision-making skills required.
• Self-directed and starter skills required.
• Demonstrated written and oral communication skills required.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.

Duties, responsibilities and activities may change at any time with or without notice.

Physical and Emotional Demands :

While performing the duties of this job, the employee is frequently required to sit. The employee is regularly required to stand;

walk; use hands to finger, handle, or feel; reach with hands and arms; climb or balance; stoop, kneel, and talk or hear.

The employee must occasionally lift and / or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, and ability to adjust focus.

Equal Employment Opportunity Policy Statement

Lucent Health Solutions, Inc. is an Equal Opportunity Employer.