Stop Loss Auditor

Lucent Health combines top-tier claims management with a compassionate, human-focused, data-driven care management solution. This approach helps self-insured employers provide care management that enables health plan participants to make smarter, cost-saving healthcare decisions. Continuous data analytics offer ongoing insights, ensuring participants receive the right care, at the right cost, at the right time. Join us as we build a company that aims to be a better health benefits partner for self-insured employers. Summary The Stop Loss Analyst supports the administration, monitoring, and reimbursement recovery of specific and aggregate stop loss claims for self-funded employer groups serviced by Lucent Health. This role holds the responsibility for identifying high-cost claimants, auditing claim and eligibility information, preparing reimbursement submissions, tracking carrier activity, and maintaining accurate documentation to support timely recovery and compliance with stop loss policy requirements.

Responsibilities

• Monitor claim activity to identify members approaching or exceeding specific deductible thresholds, including early identification of high-cost claimants.
• Review paid medical and pharmacy claims, fees, eligibility records, plan documents, and stop loss policy provisions to confirm reimbursement eligibility and accuracy.
• Prepare, organize, and submit complete reimbursement requests to stop loss carriers, managing required documentation such as claim detail, eligibility verification, paid claim reports, disclosure information, and supporting correspondence.
• Track pending, outstanding, reimbursed, denied, and pended claims; follow up with carriers, vendors, internal teams, and clients as needed to resolve open items.
• Process reimbursement payments received from stop loss carriers and coordinate with accounting, finance, claims, or client service teams to ensure accurate application and reporting.
• Support monthly and year-end aggregate reporting, accommodation requests, and claim reconciliation processes.
• Serve as a liaison between internal TPA operations, stop loss carriers, brokers, account management, underwriting, and client-facing teams regarding claim status, documentation needs, and reimbursement issues.
• Maintain accurate electronic claim files, tracking logs, reports, and audit-ready documentation in accordance with internal procedures and carrier requirements.
• Assist with internal audits, quality reviews, renewal analysis, disclosure updates, and sales or implementation support by providing stop loss claim data and trend insights.
• Identify process gaps, recurring documentation issues, or reimbursement delays and recommend improvements to strengthen operational efficiency and client service.

Qualifications

• High school diploma or equivalent required; associate or bachelor’s degree in business, healthcare administration, finance, accounting, or a related field preferred.
• One to three years of experience in stop loss, medical claims, benefits administration, healthcare operations, TPA operations, or a related field preferred.
• Working knowledge of self-funded health plans, specific and aggregate stop loss, claim funding, reimbursement processes, eligibility, and plan document requirements preferred.
• Ability to review medical and prescription drug claim detail reporting, interpret policy and plan provisions, reconcile data, and identify documentation needed to support reimbursement.
• Proficiency with Microsoft Outlook, Word, and Excel.
• Strong attention to detail, organization, follow-through, and analytical problem-solving skills.
• Clear written and verbal communication skills with the ability to collaborate across claims, account management, finance, underwriting, carriers, brokers, and clients.
• Ability to manage multiple priorities, meet deadlines, and work independently in a fast-paced TPA environment.
• Commitment to confidentiality, accuracy, compliance, and excellent service for clients and members.

COMPANY CULTURE

At Lucent Health, our success is built on employees who are honest, ethical and hardworking. We communicate transparently, act with integrity, and hold ourselves accountable for our work and decisions. We treat colleagues, clients and partners with fairness, respect and confidentiality. And we bring consistency, initiative and adaptability to everything we do, taking ownership of challenges and going the extra mile when it counts. Lucent Health is an Equal Opportunity Employer that does not discriminate based on actual or perceived race, color, creed, religion, alienage or national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity, gender expression, transgender status, sexual orientation, marital status, military service and veteran status.