Stop Loss Medical Claims Examiner

Alliant Insurance Services is one of the nation’s largest and fastest-growing insurance brokerage and consulting firms. We operate through a network of specialized national platforms and local offices to offer our clients a comprehensive portfolio of solutions built on innovative thinking and personal service. Alliant is changing the way our clients approach risk management and benefits, so they can capitalize on new opportunities to grow and protect their organizations.
More information is available on the company's website at: www.alliant.com.
SUMMARY
Responsible for reviewing, adjudicating and managing Stop LossMedical Claims in accordance with company guidelines, statutory regulations and best practices. Manages claims through well-developed action plans to an appropriate and timely resolution.
ESSENTIAL DUTIES AND RESPONSIBILITIES

• Establishes proof of loss by reviewing medical documentation presented, requesting additional information from sources such as administrators, brokers, hospitals, physicians, etc.;
• Reviews claims using a variety of file/information formats of multiple TPAs, interpreting and comparing contracts, dispersing reimbursements, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination;
• Adjudicates claims in medical Stop Loss system and approves or denies based on compliance with the SPD and the Stop Loss policy;
• Sets financial risk reserves for each Stop Loss claim filed;
• Applies the appropriate contractual provisions associated with assigned Stop Loss claims including plan specifications of the underlying plan document and professional case management resources;
• Claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim;
• Develops, coordinates and implements a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources;
• Prepares Explanation of Benefit cover letters and other correspondence as needed for claim payment to client;
• Maintains confidentiality and complies with the Health Insurance Portability and Accountability Act (HIPAA)
• Complies with agency management system data standards and data integrity (enters and maintains complete and accurate information);
• Other duties as assigned.

QUALIFICATIONS
EDUCATION / EXPERIENCE
Bachelor’s degree or equivalent combination of education and experience
Significant knowledge of Stop Loss Claims processing and the Stop Loss industry and an overall knowledge of health care industry
Knowledge of medical terminology, including CPT and HCPC codes. Revenue and ICD9 to ICD10 coding procedures and guidelines. (Familiarity with Medicare RBRVS fee schedule,
Medicare DRG Pricer schedule, Medicaid APDRG schedule and/or UB Revenue Codes is strongly desired)
SKILLS
Excellent verbal and written communication skills
Excellent interpersonal skills with ability to work in a team environment
Ability to work in a fast-paced, high volume environment
Flexibility to handle multiple priorities while maintaining a high level of professionalism
Strong attention to detail, and ability to follow detailed instructions and work independently
Available for occasional travel
Proficient in Microsoft Office Products
LI-DR1
LI-REMOTE
We are proud to provide comprehensive, high quality employee programs to meet employees’ needs now and in the future, including a very competitive financial package. We encourage you to explore what we have to offer.
For immediate consideration for this position, please click on the “Apply Now" button.
Alliant Insurance Services, Inc. is an equal opportunity employer. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of race, color, age, religion, gender, sexual orientation, gender identity, national origin, disability, protected veteran status or any other protected status.
If you are applying for a job and need a reasonable accommodation for any part of the employment process, please call our Career Center at 1-877-901-9473 and let us know the nature of your request and contact information.
For more information on Alliant Insurance Service's benefits, click here.