Senior Claims Specialist - Stop Loss

Company: Highmark Inc. Job Summary: Join our dedicated team as a Senior Claims Specialist specializing in Stop Loss claims at Highmark Inc. In this vital role, you will be responsible for the thorough review, evaluation, and processing of diverse Stop Loss (Excess Risk and Reinsurance) claims, ensuring adherence to our high standards for turnaround time and quality. You will foster strong relationships with clients, providing essential education and insights into client claim losses, while effectively communicating important information to management. Your proactive approach will ensure timely follow-ups on pending claims in line with departmental standards. Health Now Administrative Services (HNAS), a part of Highmark Health, is committed to delivering exceptional health experiences. We offer flexible and efficient solutions for employee health benefits, promoting a collaborative culture that prioritizes growth and positively affects the lives we serve. Essential Responsibilities: Accurately process incoming Stop Loss claims, addressing both initial and subsequent claims while enhancing our client service initiatives and supporting clients with guidance. Conduct in-depth 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, focusing on 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. Determine whether to pend or adjudicate claims based on organizational policies, ensuring claims are finalized within established financial thresholds and preparing pended claim letters for any incomplete or invalid claims. Identify inconsistencies in claim submissions and collaborate with the Special Investigation Unit as needed. Highlight areas for staff training, process improvements, and documentation refinement. Assist 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 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 focus on accuracy. Strong organizational and time management abilities. Ability to work independently. Robust problem-solving and analytical thinking skills. Travel Requirement: 0% - 25% Physical, Mental Demands and Working Conditions: This position is office-based and may involve teaching and training others. While some travel from the office to various worksites may be required, 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: 2026-03-05