Stop Loss Claims Analyst

Stop Loss Claims Analyst

Work from home within Oregon, Idaho or Utah. Build a career with purpose. Join our cause to create a person-focused and economically sustainable health care system.

Who We Are Looking For: Every day, Cambia's dedicated team of Stop Loss Claims Analysts is living our mission to make health care easier and lives better. As a member of the Stop Loss team, this position adjudicates all stop loss claims by developing policies and procedures to ensure consistent claim practices and adherence to policy and contract terms, appropriate laws and regulations - all in service of creating a person-focused health care experience.

Do you have a passion for serving others and learning new things? Do you thrive as part of a collaborative, caring team? Then this role may be the perfect fit.

What You Bring to Cambia: Qualifications: Stop Loss Claims Analyst would have a high school diploma or GED and 5 years of professional claims processing experience or equivalent combination of education and experience. Skills and attributes: Knowledge of when to utilize legal and clinical resources to comprehend legal and medical terminology in order to make final determinations on whether to approve or further investigate a claim. Possess strong knowledge of policy and contract terms, lasering, aggregating deductibles and eligibility to ensure correct processing of all eligible claim reimbursements. Advanced knowledge of claim reserving and settlement. Excellent communication skills for both external and internal customers. Demonstrate understanding of medical terminology and ICD-10/CPT coding. Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

What You Will Do at Cambia: Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims. Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details. Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information. Lead the process to measure, track, and report all aggregate claims. Audit all aggregate claims onsite and off-site when needed based on set dollar threshold. Provide client audit reporting as needed. Manage inventory of claims while ensuring best practices and claim standards are met. Identify new opportunities to track and process claims more efficiently. Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes. Analyze and investigate all claims, request supplementary documentation as necessary, in order to process or reprocess claims in a timely and accurate manner.

Work Environment: No unusual working conditions. Work is primarily performed in an office environment.

The expected hiring range for a Stop Loss Claims Analyst is $68,900.00 - $93,150.00 depending on skills, experience, education, and training; relevant licensure/certifications; performance history; and work location. The bonus target for this position is 6.25%. The current full salary range for this role is $64,000.00 to $106,000.00.