Seasonal Senior Claims Auditor/Consultant

Brown & Brown Insurance

. Manage and adjudicate a portfolio of complex Employer Stop Loss claims within established authority levels and in accordance with policy and contract provisions.

Posted 10/12/2026part-timeRemote • Pennsylvania • United StatesSenior💰 $65 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing and adjudicating complex Employer Stop Loss claims, including comprehensive claims analysis, auditing, and interpretation of insurance contracts. Proven ability to handle high-dollar medical claims and provide strategic recommendations for reserves and claim management.

Highest-signal resume keywords

Employer Stop Loss Claims ManagementClaims AuditingClaims AdjudicationMedical Claims AnalysisInsurance Contract Interpretation

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalysisClaims AdjudicationClaims AuditingMedical Claims ManagementReserve RecommendationsContract InterpretationEligibility ReviewPayment ReviewData AnalysisHigh-Dollar Claims Handling

Soft Skills

Problem SolvingCommunicationCollaborationAttention to DetailAnalytical Thinking

Industry Keywords

Health BenefitsInsurance EnvironmentStop Loss PoliciesContractual ComplianceClaims ProcessingTPA CollaborationMedical Records ReviewHigh-Cost ServicesPayment InaccuraciesClaim Lifecycle Management

About the role

Key responsibilities & impact

Manage and adjudicate a portfolio of complex Employer Stop Loss claims within established authority levels and in accordance with policy and contract provisions.
Review and interpret Stop Loss policies, certificates, plan documents, eligibility provisions, deductibles, exclusions, reimbursement provisions, and other contractual terms to determine claim eligibility and reimbursement.
Conduct comprehensive reviews of high-dollar, complex, and unusual claims, including significant medical expenses, transplant, oncology, catastrophic conditions, specialty drugs, and other high-cost services.
Analyze claims data, medical records, eligibility information, provider documentation, invoices, and supporting documentation to validate claim accuracy and reimbursement.
Review claims for appropriate adjudication, including eligibility, deductibles, exclusions, benefits, payment calculations, and application of policy terms.
Manage large-loss claims and provide reporting, analysis, recommendations, and escalation to the Vice President of Claims and other stakeholders.
Review and recommend reserves for large and complex claims based on available information, anticipated claim liability, policy provisions, and reserving guidelines.
Monitor large claims throughout their lifecycle and update reserves, claim estimates, and management reports.
Conduct pre- and post-payment claim audits to identify payment inaccuracies, processing errors, documentation deficiencies, and opportunities for recovery or correction.
Identify trends, recurring errors, system issues, and process deficiencies affecting claim accuracy or financial performance and recommend corrective action.
Work with TPAs and external claims administrators to resolve complex claims issues, validate claim information, and ensure contractual and administrative compliance.
Manage inquiries and escalated claim matters from brokers, TPAs, plan sponsors, Underwriting, reinsurers, and other stakeholders.

Requirements

What you’ll need

Bachelor's degree required.
Minimum of seven (7) years of progressive experience in claims, with significant experience in Employer Stop Loss, medical claims, health benefits, or a related insurance environment.
Demonstrated experience handling complex and high-dollar medical claims.
Experience with claims auditing, adjudication, payment review, and claims analysis.
Experience interpreting insurance contracts, plan documents, and claims provisions.
Experience managing large-loss claims and making reserve recommendations.

Benefits

Comp & perks

Health Benefits: Medical/Rx, Dental, Vision, Life Insurance, Disability Insurance
Financial Benefits: ESPP; 401k; Student Loan Assistance; Tuition Reimbursement
Free Mental Health & Enhanced Advocacy Services
Paid Time Off
Holidays
Preferred Partner Discounts