Job Description
Note: The job is a remote job and is open to candidates in USA. Great American Insurance Group is a leader in the insurance industry, offering opportunities for growth and collaboration. The Senior Specific Claim Auditor is responsible for managing and validating stop-loss claims, ensuring compliance with regulatory standards, and providing guidance to clients on claims procedures. Responsibilities • Receive, log, and validate incoming stop-loss claims and related documentation; request missing information as needed • Verify eligibility, plan benefits, and stop-loss policy provisions; accurately enter claim details into the system of record • Maintain electronic claim files for audit and compliance purposes. Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims; Identify cost-containment opportunities and implement strategies with carriers and TPAs • Document audit findings and maintain accurate records in the system • Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams; provide clear updates on claim status and documentation requirements • Offer guidance to clients on claims procedures and coverage issues • Ensure adherence to regulatory requirements, internal controls, and fraud prevention policies • Stay current on industry trends, regulations, and best practices; participate in special projects, reporting, and process improvement initiatives • Identify opportunities to streamline claim intake and processing workflows • Train and mentor junior claims processors on best practices • Perform other duties as assigned Skills • Minimum 10 years in medical stop-loss claims processing or related health insurance claims roles • Proficiency in medical coding (ICD-10, CPT, HCPCS) • Advanced Excel skills • Expertise with claims processing systems • Strong understanding of stop-loss insurance, plan documents, and claims handling practices • Exceptional analytical ability • Attention to detail • Strong written and verbal communication skills Benefits • Medical, dental, and vision coverage • Wellness plans • Parental leave • Adoption assistance • Tuition reimbursement • Paid Time Off • Paid holidays • A 401(k) plan with company match • An employee stock purchase plan • Commuter benefits Company Overview • Great American Insurance Group is an insurance company that specializes in in property and casualty insurance. It is a sub-organization of American Financial Group. It was founded in 1872, and is headquartered in Cincinnati, Ohio, USA, with a workforce of 5001-10000 employees. Its website is Company H1B Sponsorship • Great American Insurance Group has a track record of offering H1B sponsorships, with 2 in 2025. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job