• Receive, log, and validate incoming stop-loss claims and related documentation • 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 • 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 • Identify opportunities to streamline claim intake and processing workflows • Train and mentor junior claims processors on best practices

• Perform documentation and coding audits for all acute inpatient services for clients • Identify coding errors, compliance, and educational opportunities • Optimize reimbursement by ensuring accurate codes and documentation • Conduct independent reviews and apply coding principles • Verify coding accuracy and clinical indicators • Maintain productivity and quality goals

• Directs, provides guidance and advice, and reviews the work product of more junior Auditors and Financial Analysts to ensure that it meets the stated objectives of audit investigations. • Reports to the Trial Staff and COR as required on the status of audit investigations; prepares interim and final written reports and recommendations based on the results of audit investigations. • Reviews and analyzes financial and operating statements, records and other information in order to arrive at results and conclusions in accordance with the stated objectives of audit investigations.

• Performing physical and remote audits of insured’s business • Interviews, investigates, collects, and records information to be used in a written report that is provided to the insurance carrier.