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Responsibilities The Senior Claims Examiner and Stop Loss Coordinator is responsible for reviewing and processing complex professional and hospital claims for Community Care Health (CCH) in-network and out-of-network providers. This role will review, analyze, and research healthcare claims to identify discrepancies, verify pricing, confirm prior authorization, and process them for payment. Tracks potential and existing stop loss members, timely filing of all stop loss claims with the carrier, follow-up with the carrier regarding outstanding recoveries, and reporting.
Provides overall assurance that CCH is in compliance with the stop loss policy. Trains new or existing staff on any claims system enhancements. Ideal Background: Experience with self-funded, tribal, and non-tribal insurance plans.
Experience with Blue Shield (due to current integration). Alternative Strong Backgrounds: Medicare
- Even though the role does not handle these lines directly, The department heavily utilizes CMS guidelines in their processing, so Medicare knowledge overlaps by 80% to 90%. Qualifications Education
- High School Diploma, High School Equivalency (HSE) or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
- Associate's Degree preferred Experience
- 4 years of medical claims processing/adjudication experience required
- Experience working with claims system/applications and troubleshooting
- TriZetto/QNXT system knowledge preferred Disclaimers
s listed are an estimate and subject to change.• If any bonuses are noted, they are only applicable to external hires meeting criteria.