Note: The job is a remote job and is open to candidates in USA. Great American Insurance Group is a leader in the insurance industry, offering opportunities for growth and collaboration. The Senior Specific Claim Auditor is responsible for managing and validating stop-loss claims, ensuring compliance with regulatory standards, and providing guidance to clients on claims procedures.
Responsibilities
• Receive, log, and validate incoming stop-loss claims and related documentation; request missing information as needed
• Verify eligibility, plan benefits, and stop-loss policy provisions; accurately enter claim details into the system of record
• Maintain electronic claim files for audit and compliance purposes. Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims; Identify cost-containment opportunities and implement strategies with carriers and TPAs
• Document audit findings and maintain accurate records in the system
• Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams; provide clear updates on claim status and documentation requirements
• Offer guidance to clients on claims procedures and coverage issues
• Ensure adherence to regulatory requirements, internal controls, and fraud prevention policies
• Stay current on industry trends, regulations, and best practices; participate in special projects, reporting, and process improvement initiatives
• Identify opportunities to streamline claim intake and processing workflows
• Train and mentor junior claims processors on best practices
• Perform other duties as assigned
Skills
• Minimum 10 years in medical stop-loss claims processing or related health insurance claims roles
• Proficiency in medical coding (ICD-10, CPT, HCPCS)
• Advanced Excel skills
• Expertise with claims processing systems
• Strong understanding of stop-loss insurance, plan documents, and claims handling practices
• Exceptional analytical ability
• Attention to detail
• Strong written and verbal communication skills
Benefits
• Medical, dental, and vision coverage
• Wellness plans
• Parental leave
• Adoption assistance
• Tuition reimbursement
• Paid Time Off
• Paid holidays
• A 401(k) plan with company match
• An employee stock purchase plan
• Commuter benefits
Company Overview
• Great American Insurance Group is an insurance company that specializes in in property and casualty insurance. It is a sub-organization of American Financial Group. It was founded in 1872, and is headquartered in Cincinnati, Ohio, USA, with a workforce of 5001-10000 employees. Its website is http://www.greatamericaninsurancegroup.com.
Company H1B Sponsorship
• Great American Insurance Group has a track record of offering H1B sponsorships, with 2 in 2025. Please note that this does not guarantee sponsorship for this specific role.
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