Senior Stop Loss Claims Analyst

Job description

Company: Highmark Inc. Job Description: JOB SUMMARY This 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. ESSENTIAL RESPONSIBILITIES: ​ - Processes 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 the following: 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. This includes following a departmental claim checklist to ensure eligibility i...