The Claims Analyst performs a complete quality review and evaluation of all Stop Loss claim submissions received and logged in the David Young Claim System to determine whether the amount requested is eligible for reimbursement under the Stop Loss Policy in force. Duties and responsibilities include but are not limited to:
- Process an average of 5 to 7 claims per day.
- Maintain a processing accuracy of 99% or better.
- Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim.
- Review and adjudicate claims within approved authority limits.
- Maintain assigned claim block and assist other team members while meeting departmental guidelines.
- Elevates issues to next level of supervision, as appropriate.
- Exhibit good organizational, oral communication and interpersonal skills while working with internal and external customers.
- Document rationale of claim decisions based on review of the contractual provisions, plan specifications and the analysis of medical records, etc.