This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Health Claims Stop Loss Auditor based in United States.
This role is focused on ensuring accuracy, compliance, and integrity within high-complexity health claims through detailed stop-loss claim audits. The position plays a key part in identifying errors, validating claim handling practices, and ensuring adherence to internal procedures and regulatory requirements. It requires strong analytical ability to review large and complex claims files and translate findings into actionable insights. The role also contributes to continuous improvement by identifying patterns and recommending enhancements to claims processes. Working in a detail-oriented and collaborative environment, the auditor supports both operational excellence and risk mitigation. This is a remote position offering the opportunity to impact claims quality and financial outcomes across the organization.
Accountabilities:
- Conduct comprehensive audits of high-complexity health and stop-loss claims to ensure accuracy, compliance, and adherence to established guidelines
- Review claim documentation in detail to identify errors, inconsistencies, and potential compliance risks
- Document audit findings clearly and provide actionable recommendations for process improvement and corrective actions
- Analyze claims data to identify trends, patterns, and systemic issues impacting claims performance
- Support reporting activities by preparing audit summaries, metrics, and compliance documentation
- Collaborate with claims, risk, and operational teams to improve claim handling processes and reduce errors
- Ensure alignment with regulatory requirements, internal policies, and industry standards in all audit activities
Requirements:
- Bachelor’s degree preferred or equivalent professional experience in insurance or claims auditing
- 4–6 years of experience in claims handling, auditing, or health insurance operations
- Strong understanding of health insurance claims processes, stop-loss coverage, and regulatory requirements
- Experience working with insurance compliance frameworks and audit methodologies
- Strong analytical and critical thinking skills with high attention to detail
- Proficiency in Excel and audit or claims management systems
- Strong organizational skills with the ability to manage multiple complex files simultaneously
- Excellent written and verbal communication skills for reporting audit findings and recommendations
Benefits:
- Competitive annual salary range of $51,800–$75,000 based on experience and location factors
- Remote work flexibility within the United States
- Opportunity to work on complex, high-impact insurance audit cases
- Comprehensive benefits package including medical, dental, and vision coverage
- Retirement savings plan options
- Paid time off and company holidays
- Professional development opportunities and exposure to advanced insurance audit practices
- Collaborative and values-driven work environment focused on integrity and continuous improvement