Stop Loss Claim Auditor

Vālenz® Health

. Review and audit stop loss reimbursement requests for accurate and timely payment .

Posted 11/9/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare claims auditing, particularly in stop loss claims, with strong analytical skills for accurate reimbursement calculations and documentation management. Proficient in using automated tools for claim evaluations while ensuring compliance with regulatory standards.

Highest-signal resume keywords

Healthcare Claims AuditingStop Loss Claims AdministrationAnalytical SkillsAttention to DetailMicrosoft Excel Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claim Documentation ReviewAggregate Claim CalculationsEligibility EvaluationReimbursement ProcessesContract InterpretationPayment Integrity IdentificationCost Containment AnalysisSubrogation IssuesFMLA and COBRA KnowledgeAudit Documentation Maintenance

Soft Skills

Strong Communication SkillsOrganizational SkillsTime Management Skills

Tools & Technologies

Microsoft OfficeAI-Assisted ToolsClaim Systems

Industry Keywords

Self-Funded Medical PlansEmployer Stop Loss TerminologyTPA OperationsSummary Plan DescriptionsHealthcare Financing OrganizationsConfidentiality StandardsHIPAA Compliance

About the role

Key responsibilities & impact

Review and audit stop loss reimbursement requests for accurate and timely payment
Evaluate claim and eligibility documentation and perform aggregate claim calculations within delegated authority
Retrieve, log, organize, and review stop loss claim submissions and supporting documentation
Audit initial and supplemental reimbursement requests for eligibility, covered expenses, contract terms, deductible application, and plan or policy provisions
Perform preliminary calculations and audits for aggregate accommodations and final year-end aggregate claim submissions
Identify discrepancies, exceptions, ambiguous contract language, and matters outside delegated authority and escalate them appropriately
Obtain and evaluate eligibility, extension-of-benefits, FMLA, COBRA, precertification, accident, subrogation, UB-04, itemized bill, and other supporting documentation
Maintain complete and accurate audit documentation, calculations, determinations, and supporting records in claim systems
Review plan documents, Summary Plan Descriptions, amendments, and related materials using checklists and approved automated or AI-assisted tools
Validate automated and AI-assisted review outputs before using them in claim or plan-document decisions
Identify eligibility, coordination, cost-containment, payment-integrity, and reimbursement issues and coordinate with internal and external partners
Support high-cost claim monitoring, reserve and notification review, and related reporting
Communicate with TPAs, brokers, carriers, auditors, vendors, and internal partners regarding documentation, claim status, findings, and questions
Support claims quality reviews, reporting, research, procedure documentation, and continuous improvement initiatives
Provide backup support for claims intake and workflow activities
Perform duties in accordance with procedures, contractual requirements, delegated authority, confidentiality standards, and regulatory requirements

Requirements

What you’ll need

3+ years of experience in healthcare claims, stop loss claims, medical claim auditing, TPA operations, or a related field
Working knowledge of self-funded medical plans, employer stop loss terminology, reimbursement processes, contracts, and operational workflows
Ability to interpret plan documents, stop loss policies, eligibility information, and claim documentation
Strong analytical and mathematical skills for detailed claim audits and reimbursement calculations
Strong attention to detail and ability to maintain complete, accurate, and audit-ready documentation
Ability to independently review claims within established procedures and delegated authority and escalate exceptions or high-risk matters
Strong organizational and time-management skills
Strong written and verbal communication skills
Proficiency with Microsoft Office applications, including Excel and Word
Ability to learn stop loss administration, underwriting, and reporting systems
Ability to use approved automated and AI-assisted tools responsibly with human review and validation
Ability to handle confidential financial, claim, and member information with discretion
Must be US based and able to comply with company policies such as HIPAA
Bachelor's degree in Healthcare Administration, Accounting, Finance, Insurance, Business, or a related field is a plus
Experience auditing complex or high-dollar medical claims is a plus
Experience reviewing Summary Plan Descriptions, plan documents, stop loss contracts, or amendments is a plus
Experience with aggregate accommodation and year-end aggregate claim calculations is a plus
Experience with self-funded employers, stop loss carriers, TPAs, managing general underwriters, or related healthcare financing organizations is a plus
Experience identifying payment-integrity, cost-containment, subrogation, coordination-of-benefits, or eligibility issues is a plus
Experience with stop loss claims administration, underwriting, or reporting platforms is a plus

Benefits

Comp & perks

Generous compensation commensurate with experience and performance
Competitive benefits package with generous employer subsidies
Flexible and remote working options
401(k) with generous employer match and immediate vesting
Personal and professional development opportunities
Supportive family benefits, including paid leave for new family members
Companywide philanthropic program, Valenz Communities Connection
Necessary equipment provided for fully remote work
Generously subsidized company-sponsored Medical, Dental, and Vision insurance
Access to Healthcare Blue Book and KISx Card services
HSA, FSA, and DCFSA spending account options
Flexible working environment
Generous paid time off, including vacation, sick leave, and paid holidays
Employee Assistance Program with professional counseling, referrals, and additional services
Paid maternity and paternity leave
Pet insurance
Employee discounts on phone plans, car rentals, and computers
Community giveback opportunities, including paid time off for philanthropic endeavors