Senior Stop Loss Claims Analyst/HNAS

OverviewCompany : Highmark Inc.Job Description :JOB SUMMARYThis 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.ResponsibilitiesProcesses 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 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; follows a departmental claim checklist to ensure eligibility is met, audits the claim for duplicate line-item charges, and determines if all information is available to finalize the payment request. Refers high dollar charges to cost containment and RxOps departments for review if applicable.Determines whether to pend or adjudicate claims following organizational policies and procedures; finalizes and adjudicates claims up to pre-determined dollar thresholds; completes pended claim letters for incomplete, invalid, or missing claim information to TPAs, brokers, or customers using the appropriate application and/or template.Identifies potential discrepancies in claim submissions and involves the Special Investigation Unit as necessary; identifies issues to educate/train internal staff, streamline processes and update documentation.Assists leadership with performing client performance evaluations to assess the accuracy of client reports, 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 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 and ExperienceEducationRequired: High School Diploma/GEDSubstitutionsNonePreferredBachelor’s degreeExperienceRequired5 years of relevant, progressive experience in health insurance claims3 years of prior experience processing 1st dollar health insurance claims3 years of experience with medical terminologyPreferred:3 years of experience in a Stop Loss Claims Analyst role.SkillsAbility to communicate concise accurate information anizational skillsAbility to manage time effectively.Ability to work independently.Problem Solving and analytical skills.Other RequirementsLanguage (Other than English): NoneTravel Requirement: 0% - 25%Physical, Mental Demands and Working ConditionsPosition Type: Office-basedTeaches / trains others regularly: OccasionallyTravel regularly from the office to various work sites or from site-to-site: RarelyWorks primarily out-of-the office selling products/services (sales employees): NeverPhysical work site required: YesLifting: up to 10 pounds: ConstantLifting: 10 to 25 pounds: OccasionallyLifting: 25 to 50 pounds: RarelyDisclaimer: 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 pliance 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 HIPAA and the company Privacy Policies and Procedures and Information Security Policy.It is every employee’s responsibility to comply with the company’s Code of Business Conduct and applicable laws, rules, and regulations.Pay Range Minimum: $22.71Pay Range Maximum: $35.18Base 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 protected veteran or disability status and prohibit discrimination based on any protected category by applicable laws.We strive to make this site accessible to all users. For accessibility assistance, contact HR Services Online at Consumer Privacy Act Employees, Contractors, and Applicants NoticeReq ID: J269711 #J-18808-Ljbffr

Created: 2025-09-23