Stop Loss Claims Analyst

Stop Loss Claims Analyst – Cambia Health Solutions

Work from home within Oregon, Washington, Idaho, or Utah. The role adjudicates stop loss claims to ensure consistent claim practices, adherence to policy and contract terms, and compliance with laws and regulations.

Build a career with purpose in a person‑focused, economically sustainable health care system.

• High School Diploma or GED and 5 years of professional claims processing experience, or equivalent education and experience.
• Strong communication skills for both external and internal customers.
• Understanding of medical terminology and ICD‑10/CPT coding.
• Experience with AI tools and technologies highly desired.

• Knowledge of legal and clinical resources to comprehend terminology and make determinations on approval or investigation.
• Strong knowledge of policy and contract terms, deductibles, and eligibility to ensure correct processing of all eligible claim reimbursements.
• Advanced knowledge of claim reserving and settlement.

• Apply contract benefits accurately and identify incomplete or inappropriate claims.
• Make informed decisions regarding claim disposition.
• Lead the process to measure, track, and report aggregate claims.
• Audit aggregate claims onsite and off‑site based on set dollar thresholds.
• Manage inventory of claims while ensuring best practices and claim standards are met.
• Identify opportunities to increase efficiency and document claims for audit purposes.
• Analyze and investigate claims, request supplementary documentation as necessary, and process or reprocess claims timely and accurately.

• No unusual working conditions.
• Work is primarily performed in an office environment.

Expected hiring range: $68,900.00 – $93,150.00 (dependent on skills, experience, education, training, licensure, performance, and location). Bonus target: 10%. Full salary range: $64,000.00 – $.

• Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off and 10 company‑paid holidays.
• Market‑leading retirement plan with company match on 401(k) contributions.
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service).
• Award‑winning wellness programs that reward participation.
• Employee Assistance Fund.
• Commute and parking benefits.

We are an Equal Opportunity employer dedicated to a drug and tobacco‑free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status, or any other status protected by law. Background check required. If you need accommodation for any part of the application process because of a medical condition or disability, please email C