Stop Loss Specialist

Stop Loss Specialist

Location: Fort Wayne, IN

The primary purpose of this position is to administer the following: Specific and Aggregate claim filing, as well as reimbursement tracking as funds are received. Identify Large Case Management participants and submit referrals to designated professional outsources. Communicate and document large claimant status, invoices, fees, and savings. Set up transplant contracts.  Communicate and work with Value Added Service vendors. Send 50% notifications to reinsurers. Document inpatient and pre-approved services in pre-authorization module. Send out and document Independent Medical Reviews.  Assist with auditing and customer service duties as needed.

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Essential Duties:

• Timely filing of Specific and Aggregate Claims. Establish/ maintain shared folder by Plan Year/ Client/ Claimant. Monitor and coordinate release of E checks with Accounting. Track reimbursement requests on excel spreadsheet. Provide follow-up and fulfill requests for additional information as needed.
• Large Case Management: Referrals are entered into FACT's within 48 hours of notification. Enter monthly reports into FACT's within 4 days of receipt. Invoices are processed within 5 days of receipt. Handle incoming calls regarding Case Management. 50% notifications are filed monthly.
• Pre-Authorization Module: Research and respond in accordance with Health Care Reform Laws. Enter all precertification’s within 48 hours of receipt. Enter all Rx overrides into Caremark and pre-authorization module within 48 hours of receipt.
• Independent Medical Reviews: Send out for review in accordance with Health Care Reform laws. Diary conclusions.
• Provide backup Customer Service phone duties.
• Run monthly reports and send letters as needed for Continuity of Care. Assist with Claim negotiations for No Surprises Act as needed.

Education and/or Experience:

• HS/GED with 8-10 years’ experience; or Associates degree with 5-8 years’ experience; or Bachelors degree with 2-5 years’ experience; or MS/MBA with 0-2 years’ experience
• Education/Degree: Medical degree or certificate; Science
• Area of study in Medical & Dental Terminology; Anatomy & Physiology
• Claims Processing and/or Medical Review experience required
• Experience with Reinsurance Stop Loss and Aggregate filing preferred
• Minimum 8 years of experience

Basic Qualifications:

• Knowledge of insurance industry standards
• High level of anatomy and physiology knowledge
• Microsoft Suite experience (Word & Excel)
• Analytical Skills

WHY JOIN EPIC? 

• Ranked #17 Top Global Broker by AM Best
• Ranked #17 Top 100 Largest U.S. Broker by Business Insurance
• Awesome Benefits:  401K matching, Generous Time Off Policy, Flexible Work Options, Medical, Dental, Vision, Pet Insurance, Cancer Insurance, Wellness Programs, Employee Award Programs (Trips!).

EPIC embraces diversity in all its various forms—whether it be diversity of thought, background, race, religion, gender, skills or experience. We are committed to fostering a work community where every colleague feels welcomed, valued, respected and heard. It is our belief that diversity drives innovation and that creating an environment where every employee feels included and empowered, helps us to deliver the best outcome to our clients. 

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