Employee Stop Loss Sr. Claims Auditor at NSM Insurance Group, LLC

, , United States -

Full Time

Start Date

Immediate

Expiry Date

09 Jan, 26

Salary

0.0

Posted On

11 Oct, 25

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Adjudication, Contract Interpretation, Discrepancy Resolution, Claim Payment Review, Information Requesting, Claim Approval, Recovery Process, Claims Database Management, Client Audit Participation, Internal Audit Support, Special Projects, Detail Orientation, Problem Solving, Analytical Skills, Microsoft Office Proficiency, Knowledge of CPT Codes

Industry

Insurance

Description

Overview Carbon Stop Loss Solutions is a leading managing general underwriter (MGU) in the field of employer stop loss and managed care insurance. Carbon’s team of experts are known as the industry leader in delivering best-in-class risk solutions to effectively lower healthcare costs. Carbon’s offerings support clients and brokers in a rapidly changing healthcare market with best-in-class service, underwriting, claims support and effective cost containment strategies. Carbon Stop Loss Solutions is Novacore’s Healthcare Segment. At Novacore, we’re entering an exciting new chapter. Novacore is the newly formed specialty insurance entity created from the April 2025 sale of NSM Insurance Group’s U.S. commercial division. While we carry forward a 35-year legacy of deep industry expertise, we’re transforming what commercial insurance can be. The name Novacore reflects our ambition — nova for new and brilliant, core for strength and purpose. We’re building something bold and meaningful, and every team member plays a vital role in that mission. With more than $1.3 billion in premium across 15+ specialty insurance programs, we’re transforming the commercial insurance experience — delivering exceptional value to our agent partners and customers through smarter, faster and more collaborative ways of doing business. We specialize in tailored Property & Casualty and Accident & Health insurance solutions for niche industries, powered by advanced analytics, modern technology and a commitment to innovation at every level. Backed by strong leadership and a fresh vision, we’re bringing together the best of our past with bold new ideas to shape the future of specialty insurance. With a renewed focus, Novacore is positioned to grow and expand through strategic mergers and acquisitions — and to lead the way in the commercial insurance space. The Employee Stop Loss Sr. Claims Auditor will review, adjudicate, and audit ESL claims. In addition, the Auditor will interpret contract terms and conditions to ensure claims are paid timely, and reinsurer liabilities are recorded accurately. Responsibilities Receive claims and identify assumed contract under which claims are reported. Review claim submissions for adherence to contract terms and conditions including, but not limited to named reinsured, underwriting year, attachment method, reinsured limits and attachment point, coinsurance, and exclusions. Identify and resolve discrepancies and contractual issues with underwriters, brokers and cedents. Examine claim payments made by the Reinsured to ensure primary level claims are paid in accordance with policy terms and conditions. Request additional information from Third Party Administrators (TPAs), Reinsureds and Brokers as needed to make coverage determinations. Approve claim payments within authorized limit; for those in excess of authority, present them for management approval. Identify claims subject to recovery from outward reinsurance and complete the notification and recovery process in accordance with the reinsurance contract. Record claim activity, including payment and reserve amounts in claims database(s). Oversee the recording and issuance of claim payments to ceding companies and reinsurance brokers and prepare associated correspondence. Responsible for monthly review of pending/outstanding claims and follow up. Actively participate in the client audit process and recommend which clients to audit. Document on-site findings and prepare associated reports for appropriate use. Support internal audits performed by or on behalf of pool members by preparing files for review and responding to questions during the review. Complete special projects as needed. Qualifications 5+ years ESL claim experience. Knowledge of CPT codes, HCPCS and Revenue codes, hospital, and physician billing practices. Detail oriented with an emphasis on accuracy. Ability to multi- task and change priorities when necessary. Strong problem solving, decision making and analytical skills. Ability to work independently and as part of a team. Proficient in Microsoft office including Outlook, Excel and Word. Knowledge of the ESL Office (fka David Young System).

Responsibilities

The Employee Stop Loss Sr. Claims Auditor will review, adjudicate, and audit ESL claims while interpreting contract terms to ensure timely payments and accurate reinsurer liabilities. Responsibilities include identifying discrepancies, examining claim payments, and participating in audits.