Stop Loss Specialist / Claims Auditor

Work Location: Remote 

ASR Health Benefits, based in Grand Rapids, MI, is a rapidly growing third-party administrator of health plans, including medical, dental, vision, short-term disability, Section 125, and consumer-directed health plans.  We administer these health plans through dedicated client service teams, consisting of staff members from each department at ASR who work together to meet our clients’ needs.

Position Overview:
The Stop Loss Specialist is responsible for ensuring accuracy and compliance in the review of settled claim benefits. This role evaluates whether claims have been paid correctly according to company standards, plan provisions, and applicable procedures. The Stop Loss Specialist will identify overpayments, underpayments, and irregularities while collaborating with internal teams, external partners, and stop loss carriers to ensure efficient and compliant claim processing.

Key Responsibilities:

• Review settled claim benefits to confirm accuracy and compliance with plan provisions, policies, and procedures.
• Assess claims for correct payment based on eligibility, benefits, exclusions, limitations, coding, medical necessity, provider participation, and administrative processes.
• Report and document overpayments, underpayments, and discrepancies.
• Present large claim cases and recommendations to leadership.
• Facilitate timely claim review, reimbursement requests, and payment processing.
• Ensure compliance with stop loss carrier requirements for claim management and filing.
• Coordinate case reviews with stop loss carriers, external vendors, and leadership.
• Initiate cost-containment strategies for high-dollar claims, including collaboration with transplant networks and medical bill review partners.
• Serve as a subject matter resource for the Claims Department and Leadership Team on complex claims.

Required Skills & Qualifications:

• High school diploma required; associate or bachelor’s degree preferred (experience may be considered in lieu of degree).
• Minimum of 3 years’ experience in a Third-Party Administrator (TPA) or insurance carrier environment required.
• Stop loss experience and/or claims auditing background preferred.
• Strong mathematical, analytical, and problem-solving skills.
• Excellent communication and customer service abilities.
• Highly detail-oriented with the ability to work independently and accurately.
• Strong organizational skills with the ability to prioritize and manage multiple tasks within deadlines.
• Proficiency in Microsoft Office Suite.
• Willingness and ability to work overtime as needed to meet business demands.
• Ability to collaborate effectively with internal and external stakeholders.

Work Environment:
This is a remote position with the opportunity to work in-office or a combination of both, based on task requirements and business needs. On-site presence may be required for specific projects or assignments.

If you are a motivated individual who thrives in a dynamic environment, with a passion for the insurance industry and building relationships, we encourage you to apply!

Please visit www.asrhealthbenefits.com and navigate to the CAREERS link on the homepage to view ASR’s current openings.

ASR is an equal opportunity employer committed to creating an inclusive environment for all employees.