Accountabilities

• Investigate claims liability and determine the appropriate level of responsibility for submitted claims under aggregate insurance contracts.
• Review and interpret employer health plans, excess insurance policies, and contract documentation to ensure accurate claims processing.
• Audit monthly and year-end aggregate claims from initial review through final completion, following established quality and turnaround standards.
• Analyze claims reports, eligibility records, funding documentation, check registers, prescription reports, and related data to verify compliance with plan requirements.
• Communicate with third-party administrators (TPAs) and clients to resolve claim processing issues, obtain missing documentation, and clarify discrepancies.
• Establish, maintain, and adjust claims reserves based on current liability assessments and contract obligations.
• Determine appropriate reimbursement amounts, including identification of non-covered or out-of-contract expenses.
• Coordinate recovery efforts and obtain refunds when overpayments or excessive monthly accommodations are identified.
• Review operational processes of TPAs and clients to ensure alignment with contractual guidelines and internal standards.
• Maintain high standards of accuracy, confidentiality, productivity, and customer service throughout the claims auditing process.

Requirements

• Bachelor’s degree in Business Administration, a related field, or equivalent combination of education and professional experience.
• Minimum of 2 years of relevant and progressive experience in claims auditing, insurance operations, healthcare claims, or a related field.
• Broad understanding of claims auditing principles, practices, procedures, and insurance operations.
• Strong medical knowledge, including ICD-10 codes, CPT codes, medical terminology, COBRA, and HIPAA requirements.
• Ability to interpret complex documents, including benefit plans, claims reports, contracts, and procedural manuals.
• Strong analytical and organizational skills with the ability to manage multiple priorities and meet deadlines.
• Excellent written and verbal communication skills with a focus on professionalism, confidentiality, tact, and diplomacy.
• Detail-oriented mindset with strong problem-solving abilities and the ability to identify discrepancies and recommend appropriate actions.

Benefits

• Competitive salary range of $50,500 to $111,500, depending on geographic location, qualifications, experience, education, and skill level.
• Fully remote work opportunity within the United States.
• Comprehensive medical, dental, and vision insurance coverage beginning on the first day of employment.
• Basic life insurance and disability coverage.
• 401(k) retirement plan with a 6% company match.
• 20 days of paid time off, floating holidays, paid holidays, and volunteer time off.
• Paid parental leave.
• Access to wellness programs, mental health resources, fitness network memberships, and mindfulness tools.
• Student loan matching program.
• Employee discount programs.
• Opportunities for professional development, career growth, and continued learning.
• Opportunity to contribute to meaningful work within a specialized insurance environment.