Claims Operations Analyst - Medical Stop Loss


Boston, MA

Industry: Business Services


Less than 5 years

Posted 271 days ago

  by    Mason Ingling

This job is no longer available.

Provide support services to Operations and Claims departments by reviewing paid claims to ensure accuracy in collaboration with the Coding and Audit Specialist, working with the Reinsurance vendor on stop loss cases, and acting as a resource to IT staff during design and implementation of new systems or regulatory requirements.


The Job:


*** Conduct healthcare administrative functions including claims processing, remittance advice processing, eligibility verification, etc.


*** Track, manage, and submit the claims to organization reinsurance and stop loss vendor.


*** Participate in preparation for regulatory oversight audits, including Office of the Insurance Commissioner, Centers for Medicare and Medicaid Program Audits, Data Validation, and Healthcare Effectiveness Data and Information Set.


*** Ensure compliance with reporting, fulfillment, and payment of Centers for Medicare and Medicaid required incentive programs such as Physician Quality Reporting System, Pre-Existing Condition Insurance Plan, and e-Rx.


*** Implement data standardization for data warehouse and resolve Encounter Data Processing System compliance errors in preparation for submission to Centers for Medicare and Medicaid.


*** Help extract and document business requirements for system changes and implementations, develop test cases to ensure thorough testing, and produce complete and accurate documentation.


*** Collect, review, and prepare summary of findings for annual Delegation Audits.


*** Develop knowledge of ICD-9, ICD-10, CPT-4, HCPCS, DRG and APC, and ICD-9-CM coding.


Excellent opportunity comes with an industry competitive compensation package, tuition reimbursement, bonuses, 401(k) plans, medical and dependent care plan, employee assistance program, generous paid vacation time, numerous professional growth opportunities, education assistance, and more!


Please reference #37706152 when responding.

Education Requirements: BachelorDegree

Minimum Experience Requirements: 2-5 years

WE ARE AN EQUAL OPPORTUNITY EMPLOYER and our employment decisions are made without regard to race, color, religion, age, sex, national origin, handicap, disability or marital status. We reasonably accommodate individuals with handicaps, disabilities and bona fide religious beliefs.


DISCLAIMER: We will make every effort to consider applications for all available positions and shall use one or more of the contact methods and addresses indicated in resume or online application. Indicated location may be proximate or may be desirable point of embarkation for paid or unpaid relocation to another venue. Job descriptions may fit single or multiple presently available or anticipated positions and are NOT an offer of employment or contract implied or otherwise. Described compensation is not definite nor precise and may be estimated and approximate and is negotiable depending on market conditions and candidate availability and other factors and is solely at the discretion of employers. Linguistics used herein may use First Person Singular and First Person Plural grammatical person construction for and with the meaning of Third Person Singular and Third Person Plural references. We reserves the right to amend and change responsibilities to meet business and organizational needs as necessary. Response to a specific posting or advertisement may result in consideration for other opportunities and not necessarily the incentive or basis of the response. Nothing herein is or may be considered a promise, guarantee, offer, pledge, agreement, contract, or oath.


$80K - $110K