Senior Stop Loss Claims Consultant

Company: Highmark Inc. Job Summary: Become a vital member of our dynamic team as a Senior Stop Loss Claims Consultant at Highmark Inc. In this key role, you will expertly evaluate and process a variety of Stop Loss (Excess Risk and Reinsurance) claims, ensuring adherence to our high standards for quality and turnaround time. You will build strong relationships with clients, providing vital insights into claim losses and effectively communicating important information to management. Your proactive follow-ups on pending claims will enhance our overall client service and align with departmental standards. At Health Now Administrative Services (HNAS), a part of Highmark Health, we are committed to delivering exceptional health experiences. We provide flexible and effective solutions for employee health benefits, nurturing a collaborative culture that focuses on growth and positively impacting the lives we serve. Essential Responsibilities: Process incoming Stop Loss claims efficiently, overseeing both initial and subsequent claims with an emphasis on enhancing client service and advising clients. Conduct in-depth evaluations of claims submitted by Third Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) for self-funded clients, ensuring compliance with policy provisions and regulations. Analyze complex potential claims, focusing on loss control and managed care effectiveness; verify eligibility, assess reimbursement requests for accuracy, and ensure completeness before claim finalization. Refer high-cost charges to cost containment and RxOps departments as necessary. Make informed decisions to pend or adjudicate claims based on organizational policies, ensuring claims meet financial thresholds and preparing correspondence for incomplete or invalid claims. Identify inconsistencies in claim submissions and collaborate with the Special Investigation Unit as needed, while also pointing out areas for team training, process improvements, and documentation enhancements. Assist leadership in evaluating client performance, including the accuracy of client reports, operational efficiency, and evaluation of existing systems and procedures. Authorize claim payments for various clients while providing consultation to ensure client satisfaction with our services. Maintain accurate and organized records for all processed claims. Perform additional related duties as required. 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 strong commitment to accuracy. Excellent organizational and time management abilities. Ability to work both independently and collaboratively. Strong 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. 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: 2026-03-11