Stop Loss Auditor

About Crumdale Specialty

Crumdale Specialty is a diversified insurance firm providing custom solutions to businesses nationwide. We leverage industry expertise, superior talent, and a disruptive mindset to deliver agile, transparent, and cost-saving solutions that optimize self-funded health plans. Our company culture is rooted in alignment, innovation, and integrity, and we are proud to be recognized as one of Inc. Magazine’s Best Places to Work.

Position Summary

The Senior Stop Loss Analyst oversees stop loss claims within our Health Plan Services. This role requires strong analytical skills, attention to detail, and effective coordination with internal teams and external partners to ensure accurate claim processing and compliance.

Key Responsibilities

• Specific Stop Loss Claims
• Coordinate internally as well as externally with TPAs and claim audit vendors on claim questions or issues
• Identify, track, escalate and resolve pending claims
• Work with carrier partners to properly document certain approvals and facilitate the timely carrier review of claims when appropriate
• Aggregate Stop Loss Claims
• Identify when full year-end aggregate audits are needed
• Coordinate claim submission to external aggregate audit vendor
• Review audit reports, research issues identified, and recommend next steps to close out
• Ensure Rx rebates are applied and reported
• Level-Funding Analysis
• Track Level-Funded group activity
• Utilize database to identify groups with funding needs, analyze funding and claim activity, including in-process claims, to determine action needed
• Verify TPA funding reporting matches our funding activity; work with TPA to reconcile discrepancies
• Compile reporting and submit to carriers as necessary
• Additional Responsibilities
• May be assigned by the manager as needed 

• 5+ years of Stop Loss claims auditing experience.
• Strong understanding of stop loss insurance principles and in-depth knowledge of medical insurance claims.
• Excellent communication and interpersonal skills, with the ability to collaborate effectively across departments and with external partners.
• Strong analytical skills with proficiency in data analysis and interpretation.
• Detail-oriented mindset with a focus on accuracy and compliance.
• Ability to prioritize tasks and manage multiple responsibilities in a fast-paced environment.
• Proficiency in Microsoft Office Suite and database management tools.
• Knowledge of relevant regulations and industry standards pertaining to insurance and claims management is preferred.
• Ability to handle sensitive or confidential information and maintain confidentiality at all times

Why Join Crumdale?

• Be part of a fast-growing, innovative company redefining self-funded healthcare.
• Work with industry experts and cutting-edge technology.
• Enjoy a culture that values alignment, innovation, and integrity.

At Crumdale, we strive to provide a comprehensive and supportive benefits package to ensure the well-being of our employees. Our benefits include:

• Medical
• Telemedicine
• Dental
• Vision
• Life, AD&D, Disability
• 401(k)
• Flexible Time-off

Please note: Crumdale Specialty is not engaging with external recruitment agencies; please refrain from contacting us regarding this position.