Claims Director-Medical Stop Loss

Radion Health is the exclusive managing general agent for medical stop loss insurance for Great American Insurance Company. Radion Health makes it possible for advisors and program managers to offer awesome, affordable health insurance to small employer groups without claims experience.

We are seeking a detail-oriented and experienced Stop Loss Claims Director to join our energetic and growing team. The ideal candidate will have a strong background in medical stop loss insurance and a thorough understanding of claims processing and adjudication, and is excited about using their expertise to improve processes. The Claims Director will be responsible for triaging, reviewing, analyzing, and processing claims in accordance with policy terms and regulatory requirements. This role will also focus on identifying potential fraud and cost-containment opportunities to mitigate claims-related expenses.

Key Responsibilities: ? Receive and document medical stop loss claims in the system of record. ? Triage incoming claims to prioritize based on potential severity and complexity. ? Review and adjudicate medical stop loss claims in a timely and accurate manner and record decision rationale. ? Conduct thorough investigations of claims, including verifying eligibility, Plan benefits, stop loss policy requirements, and gathering and analyzing medical records, bills, and other pertinent information. ? Review and record claims notices and reporting from the Third-Party Administrator (TPA) to identify and mitigate potential high-dollar claims. ? Identify and investigate potential fraud, taking appropriate action in accordance with company policies. ? Analyze claims to identify cost-containment or savings opportunities and implement strategies, in collaboration with our strategic partners and carriers, to mitigate claims-related expenses. ? Communicate effectively with claimants, policyholders, healthcare providers, and other stakeholders to gather necessary information and provide updates on claim status. ? Maintain detailed and accurate records of all claims and related activities. ? Provide support and guidance to policyholders and clients regarding claims procedures and coverage issues. ? Collaborate with other departments, including product, underwriting, finance, and legal, to ensure seamless risk analysis, claims processing, reimbursement, and resolution. ? Stay current with industry trends, regulations, and best practices related to medical stop loss insurance and claims adjudication. ? Special projects and reporting/analysis may be required.

Qualifications: ? Bachelor?s degree in a related field or equivalent work experience. ? Minimum of 5 years of experience in medical stop loss claims adjusting or a related field. ? Minimum of 1 year in a claims leadership role. ? Strong knowledge of medical terminology, coding, and billing practices. ? Excellent analytical and problem-solving skills. ? Strong attention to detail and accuracy. ? Effective communication and interpersonal skills. ? Ability to work independently and manage multiple tasks simultaneously. ? Proficiency in using claims management software and other relevant technology

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