Stop Loss Claims Analyst

** Build a career with purpose. Join our*
* ** to create a person-focused and economically sustainable health care system.
** Every day, Cambia’s dedicated team of Stop Loss Claims Analysts is living our mission to make health care easier and lives better. As a member of the Stop Loss team, this position adjudicates all stop loss claims by developing policies and procedures to ensure consistent claim practices and adherence to policy and contract terms, appropriate laws and regulations – all in service of creating a person-focused health care experience.
* Knowledge of when to utilize legal and clinical resources to comprehend legal and medical terminology in order to make final determinations on whether to approve or further investigate a claim.
* Possess strong knowledge of Policy and Contract terms, lasering, aggregating deductibles and eligibility to ensure correct processing of all eligible claim reimbursements.
* Advanced knowledge of claim reserving and settlement.
* Excellent communication skills for both external and internal customers
* Demonstrate understanding of medical terminology and ICD-10/CPT coding.
* Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.
* Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired
* Accurately apply contract benefits within guidelines and recognize incomplete or inappropriate claims. Recognize all policies and procedures that apply to claim and be able to quickly reference documentation for details.
* Make informed decisions regarding the disposition of claim; may include payment or denial of claim, or requests for further information.
* Lead the process to measure, track, and report all aggregate claims.
* Audit all aggregate claims onsite and off-site when needed based on set dollar threshold. Provide client audit reporting as needed.
* Manage inventory of claims while ensuring best practices and claim standards are met.
* Identify new opportunities to track and process claims more efficiently. Thoroughly document claims throughout the adjudication process so they can be understood by the team and for audit purposes.
* Analyze and investigate all claims, request supplementary documentation as necessary, in order to process or reprocess claims in a timely and accurate manner.
* Work alongside diverse teams building cutting-edge solutions to transform health care.
* Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
* Grow your career with a company committed to helping you succeed.
* Give back to your community by participating in Cambia-supported outreach programs.
* Connect with colleagues who share similar interests and backgrounds through our employee resource groups.
* Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
* Annual employer contribution to a health savings account.
* Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
* Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
* Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
* Award-winning wellness programs that reward you for participation.
* Employee Assistance Fund for those in need.
* Commute and parking benefits.

Everyone is a health care consumer deserving of a simpler, more personalized experience.  is transforming the health care system to revolve around people. For over 100 years we’ve designed people-first health solutions rooted in the nation’s first health plan, a loggers’ wage pool established in the Pacific Northwest. Today that pioneering spirit aligns our family of over 20 companies, including 4 not-for-profit  serving over 3 million Americans.

Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices..###
* Information about how Cambia Health Solutions collects, uses, and discloses information is available in our .
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