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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in processing Stop Loss claims and applying contractual provisions to determine reimbursement decisions. Strong ability to manage financial risk while maintaining high-quality standards and effective communication with stakeholders.
Highest-signal resume keywords
Stop Loss Claims ProcessingClaims ManagementContractual Provisions InterpretationNegotiation and PersuasionMicrosoft Office Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingReimbursement AnalysisMedical-Record AnalysisCost-Containment InitiativesEligibility Determination
Soft Skills
Team CollaborationWritten CommunicationVerbal CommunicationProfessionalismMultitasking
Industry Keywords
Health Care IndustryStop Loss IndustryFinancial Risk ManagementCustomer ServiceAction Plan Development
About the role
Key responsibilities & impact- Review claims and interpret and compare contracts
- Disperse reimbursement and ensure claims contain required documentation
- Apply contractual provisions, underlying plan specifications, professional case management resources, and claims practices to determine reimbursement or denial
- Provide customer service and manage financial risk for an assigned block of Stop Loss claims
- Develop, coordinate, and implement an action plan for each accepted claim
- Ensure claims are effectively managed and cost-containment initiatives are implemented with clinical resources
- Determine claim eligibility in a timely manner
- Maintain the claim block and meet departmental production and quality metrics
- Prepare written rationales for claim decisions based on contractual provisions, plan specifications, and medical-record analysis
- Engage internal and external medical, investigative, and legal resources
- Establish cooperative and productive relationships with professional resources
Requirements
What you’ll need- A minimum of three to five years’ experience processing first dollar medical claims or stop loss claim processing
- Demonstrated ability to work as part of a cohesive team
- Strong written and verbal communication skills
- Knowledge of Stop Loss Claims and Stop Loss industry preferred
- Demonstrated success in negotiation, persuasion, and solutions-based underwriting
- Ability to work in a fast-paced environment and handle multiple priorities while maintaining professionalism
- Overall knowledge of the health care industry
- Proficiency using the Microsoft Office suite of products
Benefits
Comp & perks- Generous vacation and sick time
- Paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support
- Reasonable accommodations for individuals with disabilities or special disabled veterans