Claims Auditor, Stop Loss - Aggregate

The Medical Stop Loss Aggregate Auditor is responsible for reviewing and validating medical stop loss aggregate claim reimbursements by auditing claim data, eligibility, plan provisions, and contract terms. This role helps ensure aggregate reimbursements are accurate, compliant, and well-documented, while identifying variances, recoveries, and process improvements.

Key Responsibilities

Aggregate Reimbursement Audit & Validation

• Audit aggregate stop loss submissions (weekly/monthly/quarterly/annual) to confirm accuracy of: Paid claims , Contract basis , Attachment point , Aggregate deductible.
• Confirm appropriate treatment of: Coordination of Benefits (COB), subrogation, third-party recovery offsets, Provider credits/refunds, Rx rebates (if contractually relevant), and overpayment recoveries, Stop loss contract exclusions and limitations

• Reconcile eligibility/enrollment counts to: Determine correct aggregate factors and deductible calculations, Validate coverage tiers and effective dates
• Reconcile TPA/Group check registers and electronic fund transfer (EFT) files against the employer’s actual corporate bank statements to confirm funding of paid claims.
• Identify discrepancies in eligibility files (late adds/terms, dependent status issues, retro changes).

• Review Plan & Contract Interpret - Stop loss policy/certificate, endorsements, and amendments, Administrative Services Agreement (ASA) where relevant, Plan documents/SPDs and claim payment policies
• Ensure audits align with contractual provisions and internal guidelines.
• Communicate with underwriting, TPA’s, brokers/producers to resolve discrepancies in banking transactions, funding or any other claim issues.

Required Qualifications

• 2+ years of experience of Stop loss Aggregate claim handling.
• Working knowledge of: Aggregate stop loss concepts (attachment points, factors, contract basis, reimbursements), Medical claims components (allowed vs. paid, reversals/adjustments, claim timing), Eligibility/enrollment reconciliation. Funding verification.
• Strong analytical skills with attention to detail and ability to interpret plan/contract language.
• Proficiency with Excel (pivot tables, XLOOKUP/VLOOKUP, filtering, data validation; comfort with large datasets).

Compensation & Benefits

The applicable base salary for this opportunity is $65,000.00 - $85,000.00. The base pay offered will be determined by factors such as experience, skills, training, location, certifications, education, and any applicable minimum wage requirements. In addition to the base salary, this opportunity may be eligible for performance-based incentives.​ We are excited to offer a competitive total rewards package which includes health and welfare benefits, tuition and professional certification assistance, 401k savings, elective participation in the Employee Stock Purchase Program, paid time off, paid holidays, and child bonding leave, as well as other employee assistance.

Originally posted on Himalayas