Senior Claims Consultant - Stop Loss

Company: Highmark Inc. Job Summary: Join our passionate team as a Senior Claims Consultant specializing in Stop Loss claims at Highmark Inc. In this essential role, you will expertly review, evaluate, and process a range of Stop Loss (Excess Risk and Reinsurance) claims. Your work will uphold our high standards for turnaround time and quality, while you build strong relationships with clients, providing key insights into claim losses, and communicating vital information to management. Your proactive follow-ups on pending claims will align with our departmental standards and enhance overall client service. Health Now Administrative Services (HNAS), a division of Highmark Health, is dedicated to providing exceptional health experiences. We offer flexible and effective solutions for employee health benefits, fostering a collaborative culture that prioritizes growth and positively impacts the lives we serve. Essential Responsibilities: Efficiently process incoming Stop Loss claims, managing both initial and subsequent claims with a focus on enhancing client service initiatives and providing guidance to clients. Conduct thorough evaluations of claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) on behalf of self-funded clients, ensuring compliance with policy provisions and relevant regulations. Analyze complex potential claims, emphasizing loss control and managed care effectiveness; verify eligibility, assess accuracy of reimbursement requests, and ensure completeness before finalizing claims. Refer high-cost charges to cost containment and RxOps departments as necessary. Decide whether to pend or adjudicate claims based on organizational policies, ensuring claims are finalized within established financial thresholds and preparing pended claim letters for incomplete or invalid claims. Spot inconsistencies in claim submissions and collaborate with the Special Investigation Unit as needed. Highlight areas for staff training, process improvements, and documentation refinement. Support leadership with client performance evaluations, assessing the accuracy of client reports, efficiency in claim operations, and the adequacy of our systems and procedures. Authorize claim payments for multiple clients while also providing counsel to ensure client satisfaction with our services. Maintain well-organized and precise records of all processed claims. Perform other related duties as assigned. Education: Required: High School Diploma/GED Preferred: Bachelor's degree Experience: Required: 5 years of progressive experience in health insurance claims. 3 years of experience processing first dollar health insurance claims. 3 years of experience with medical terminology. Preferred: 3 years of experience in a Stop Loss Claims Analyst role. Skills: Effective communication skills with a commitment to accuracy. Strong organizational and time management skills. Ability to work independently and collaboratively. Robust problem-solving and analytical thinking abilities. Travel Requirement: 0% - 25% Physical, Mental Demands and Working Conditions: This position is office-based and may involve teaching and training others. Some travel from the office to various worksites may be required, although extensive travel is not anticipated. Candidates should be able to lift up to 10 pounds frequently and occasionally between 10 to 25 pounds. Disclaimer: This job description provides a general overview of the nature and essential duties of this position. It does not encompass all duties or qualifications required to perform this job. Compliance Requirement: This position adheres to ethical and legal standards as outlined in company policies, including compliance with HIPAA regulations and company privacy and security policies. Pay Range Minimum: $22.71 Pay Range Maximum: $35.18 Highmark Health and its affiliates are committed to diversity and do not discriminate based on any protected status.

Created: 2026-03-04