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Stop Loss Auditor

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Daley and Associates

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Location:
United States

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Category:
Insurance

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Contract Type:
Not provided

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Salary:

65000.00 - 75000.00 USD / Year
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Job Description:

A Connecticut based Medical Insurance company is seeking an experienced Stop Loss Auditor to join a fully remote team supporting medical stop loss insurance operations. This role focuses on auditing high-cost medical claims, evaluating liability under stop loss policies, and ensuring accurate and compliant reimbursement.

Job Responsibility:

  • Audit medical stop loss claims for assigned clients
  • Review and approve Plan Documents to ensure compliance
  • Evaluate reimbursement requests and determine claim validity
  • Verify claims are paid according to Plan Documents and Stop Loss policies
  • Confirm participant and dependent eligibility
  • Review high-cost claims for financial accuracy, coding accuracy, and cost containment coordination
  • Process claim reimbursements on behalf of carriers/reinsurers
  • Maintain accurate and detailed claim documentation
  • Meet established accuracy and turnaround time standards
  • Identify and recover overpaid claims through refund requests
  • Partner with TPAs throughout the approval process
  • Maintain professional relationships with internal teams and external clients
  • Participate in cross-training opportunities as business needs allow

Requirements:

  • 3+ years of medical stop loss insurance experience (required)
  • Experience auditing stop loss or first-dollar medical claims
  • Strong knowledge of: Plan Documents and Stop Loss policies, Reinsurance contracts, Medical terminology and coding (ICD-10, HCPCS, CPT-4)
  • Ability to work independently in a remote environment while collaborating with a team

Additional Information:

Job Posted:
March 21, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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