Stop Loss Claims Analyst

Job Summary:
This position is responsible for reviewing claims, interpreting plan language, and ensuring that all claims contain the required documentation to support the claim determination. This requires applying the appropriate contractual provisions; plan specifications of the underlying plan document; professional case management resources; and claims practices, procedures and protocols to the medical facts of each claim to decide on reimbursement or denial of a claim.

The incumbent is accountable for developing, coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively and all cost containment initiatives are implemented in conjunction with the clinical resources.


• Bachelor's degree preferred 
• A minimum of five years’ experience processing first dollar medical claims
• Demonstrated ability to work as part of a cohesive team
• Strong written and verbal communication skills
• Significant knowledge of Stop Loss industry preferred, but not required
• Demonstrated success in negotiation, persuasion, and solutions-based underwriting
• Ability to work in a fast-paced environment; flexibility to handle multiple priorities while maintaining a high level of professionalism
• Overall knowledge of health care industry
• Proficiency using the Microsoft Office suite of products

Essential Functions and Responsibilities:
• Determine, on a timely basis, the eligibility of assigned claim by applying the appropriate contractual provisions to the medical facts and specifications of the claim

• Apply the appropriate contractual provisions from the underlying plan document/policy) especially with regard to eligibility and exclusions

• Maintain claim block and meet departmental metrics

• Have an awareness of industry claim practices

• Explain rationale of claim decision based on review of the contractual provisions and plan specifications and the analysis of medical records

• Knowledge of legal risk and regulatory/statutory guidelines HIPPA, privacy, Affordable Health Care Act, etc.

• Understand where, when and how professional resources both internal and external, e.g. medical, investigative and legal can add value to the process

• Establish cooperative and productive relationships with professional resources

• Other duties as assigned


Please send your resume and completed application to CHP Human Resources at:

Mail: Consolidated Health Plans, Human Resources, 2077 Roosevelt Avenue, Springfield, MA 01104-3503

Fax: (413) 452-5329 Attn. Human Resources


Phone: (413) 733-4540 ext. 258


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For more information contact us at or call us at (413) 733-4540 ext. 258