Stop Loss Coordinator

Independent Health

1d•$24 - $26

About The Position

The Stop Loss Coordinator will be responsible for operational support functions that include client annual reporting, analytical reporting, benefit analysis, and various internal reports in accordance with each client’s specific stop loss policy. The Coordinator will be responsible for maintaining goals in accuracy, productivity, and timeliness. They will respond to internal customer inquiries from departments including but not limited to Client Services, Claims Operations, Customer Service, and Sales on claim status related to stop loss policies. The Coordinator will be responsible for accurately identifying operational stop loss issues and offer sound recommendations for resolution as required. The Stop Loss Coordinator will work independently and maintain workflow with minimal supervision and demonstrate problem-solving and decision-making skills. They will coordinate efforts to control medical expenses through negotiation with nonparticipating providers, facilitation of efforts with cost containment vendors, and cross functional operational initiatives. They will contribute to research and implementation of industry best practices in cost containment and ensure appropriate reimbursement for specific negotiated care management cases. Duties will also include assisting case managers in negotiating non-participating providers/non-contracted, out of area services, the preparation of monthly savings reports by line of business, notifying reinsurance carriers of high dollar cases and ensuring proper and timely payment of such claims.

Requirements

High school diploma or GED required.
Two (2) years of experience in stop loss, claims operations, financial analytics, customer service, or client services required.
Ability to meet performance goals, including accuracy and productivity.
Working knowledge of medical and dental benefit designs and interpretations.
Excellent written, verbal, and interpersonal communication skills.
Knowledge of negotiation strategies related to healthcare claims.
Effective organizational and time management skills.
Must be able to work independently without supervision and have experience in exercising appropriate decision making.
Exhibit initiative and self-motivation, with ability to effectively solve problems as they arise.
Advanced Word and Excel skills. Knowledge of formulas and formatting skills are required.
Proven examples of displaying Nova’s Core 4: Act with Passion, Work Together, Be Accountable, Build Trust.

Nice To Haves

Associates degree preferred.
Self-funded healthcare experience preferred.
Knowledge of self-funded insurance and stop loss insurance preferred.

Responsibilities

Negotiate claim reimbursement based on client’s plan document and policies and procedures.
Analyze problems systematically, organize information, identify underlying causes and generate solutions while recognizing the impact on stakeholders and the organization.
Identify, analyze, track and interpret medical records and reimbursement.
Evaluate claim potential and identify high dollar risks.
Prepare and document written rationale of claim negotiation decisions based on plan specifications and the analysis of the medical records.
Secure the appropriate pricing for non-participating/non-contracted provider claims to include physician, hospital, and ancillary providers for all lines of business. Pricing direction may come from UM authorization, individual negotiated provider contracts, case management authorization, benefit and policy interpretations, regulatory and UCR software products, and pricing vendors and wrap networks.
Ensure timely claims payment for designated claims requiring negotiations/repricing activity.
Maintain production and savings targets according to established goals and objectives.
Enter administrative authorizations on the system as appropriate, to facilitate claims payments.
Manage efforts for pre-payment negotiation.
Work collaboratively with cross functional teams.
Demonstrate, manage and maintain Stop Loss relationships with multiple carriers.
Ensure carrier procedural requirements are updated.
Designated contact person for all issues related to stop loss for assigned groups, both internally and externally to include coordination of interdepartmental process when necessary (e.g. advance funding processes, special claim handling, check runs, check pulls).
Follow-up as needed on all negotiations and stop loss filings and communicate with the client, broker and/or stop loss carrier as necessary.
Prepare and submit claims for advance funding and/or reimbursement to the stop loss carrier.
Research individual claim disputes and provide resolution.
Responsible for internal and external customer satisfaction in the resolution of claim specific issues.
Maintain record of reimbursement check disbursement and route reimbursements back to the client.
Track and manage, on a timely basis, the eligibility of claims based on the clients plan document to ensure accurate reimbursement or denial of a claim.
External communication with providers, as required, to secure optimal claims pricing and provide written confirmation and follow-up to support negotiated rates.
Provide rationale during claim negotiation while maintaining a professional and trustworthy demeanor.
Finalize claims once a negotiated price has been secured and coordinate the payment and posting of claims as per negotiated contracts.
Reconcile vendor recoveries and initiate reimbursement claims.
Manage the monthly stop-loss ending process to include notification to appropriate interdepartmental teams, clients and/or brokers.
Track reimbursement claims and support finance for accurate payment reconciliation.
Develop and produce client and stop‑loss carrier reporting, including ad hoc requests; track and report negotiated and reimbursed savings; prepare monthly cost containment and savings reports reflecting vendor recoveries, pricing, and cost containment unit activity in coordination with internal operations.