Reinsurance Analyst
Description
JOB DESCRIPTION SUMMARY
This position reports to the Manager Claims Operations in a production environment and is responsible for supporting the various departments within the company to provide claims services to reinsurance carriers to reimburse medical claims to the Company’s Trust, Third-Party Administrator (TPA), and Managing General Underwriter (MGU). The Sr. Reinsurance Analyst is responsible for reviewing claims, interpreting and comparing contracts, dispersing reimbursement, and ensuring that all claims contain the required documentation to support the Stop Loss claim determination. They will be analyzing data and critical quality metrics for the department and be the subject matter expert for the team in reviewing supporting documentation, client and reinsurance reporting. This role assists in the documentation of policies, procedures, and controls and monitors compliance with internal controls.
QUALIFICATIONS
• Bachelor’s degree preferred and three to five years of experience related insurance/reinsurance
industry experience, required.
• Knowledge of reinsurance principles, practices, procedures, products, and services.
• Proven ability to meet tight deadlines, work under pressure and respond to changing priorities.
• Knowledge and experience of International Statistical Classification of Diseases and Related Health Problems (ICD-9, ICD-10), Current Procedural Terminology (CPT), Healthcare Common Procedure
Coding System (HCPCS II & III), coordination of benefits, Medicare, Hospital claims, surgery claims,
subrogation, and accident claims.
• Strong knowledge of self-funding, complex or catastrophic claims or billing.
• Proficient with medical coding and terminology comprehension.
• Excellent verbal and written communication skills.
• Working knowledge of Employee Retirement Income Security Act of 1974, (ERISA) claims
processing/adjudication guidelines.
• Exceptional organizational, time management, analytical and problem-solving skills.
• Exceptional knowledge in Microsoft office suite (Word, Outlook, Excel, PowerPoint) and business related software.
DUTIES AND RESPONSBILITIES
Claim Submission
• Gather, organize, and review all necessary claim information required to submit excess loss claims
(stop loss claims) to various individual Reinsurance Carriers to ensure maximum reimbursement.
• Submit claims, following Carrier Guidelines, based on reports generated after each payment run.
• Insure claims processed within the MEWA, ERISA, and California Department of Insurance standards,
as they apply.
• Support clients, carriers, and brokers at every step involved in the completion of the claim
reimbursement process.
• Monitor large case management files with the utilization review, eligibility unit, and claims examiners.
• Assist with high-level appeals.
• Answer inquires related to Advance Funding
• Assist internal claim examiners and the legal department when necessary to resolve complex
settlement issues
• Prepare written rationale of claim decision based on a review of the contractual provisions and plan
specification and the analysis of the medical condition.
• Monitor catastrophic health claims for Pinnacle Claims Management Inc. (PCMI) & Western Growers
Assurance Trust (WGAT) to eliminate the possibility of lost reimbursements.
Reporting & Analytics
• Review and evaluate complex reinsurance administration tasks to identify systematic trending issues and data anomalies; provide recommendations for best practices for problem resolution and
adherence to reinsurance contracts, including processing/tracking reinsurance claims and reinsurance
treaty review and maintenance.
• Analyze claims data, diagnosis reports, and utilization review data to identify potential high dollar
claimants
• Ensure data quality and compliance on administration systems; communicate and implement
new/revised reinsurance business processes.
• Supports monthly and quarterly administration by reviewing and processing coverage exceptions and reports, with some accountability for process review and oversight.
• Prepare and send required monthly reports for brokers, carriers, and clients.
• Prepare and provide last quarter reporting to Account Managers as they prepare for client renewal.
• Ensure timely responses to customer inquiries and requests for data information.
• Send all specific, aggregate, and potential loss reporting to respective groups by the required monthly
deadline.
• Send out End of Contract notifications to prepare for final payment runs.
• Identify potential ongoing high dollar claimants for disclosure at renewal
• Review loss notices, confirm coverage provided under the reinsurance contract terms and conditions,
identify any coverage issues or differences in coverage between the reinsurance contract and
underlying primary coverages.
• Ensure reinsurance ledgers show all transactions for a specific period and reconciliations are
conducted.
• Analyze and monitor high dollar claims to ensure maximum and prompt reimbursement receipt (goal
18 days) of submission documents.
• Monitor tracking sheets for Aggregate, Specific, and Potential reporting.
• Complete the Reinsurance Executive Summary.
• Maintain transplant lists.
Operations
• Ensure compliance by auditing internal procedures through examinations of records, reports, and
operating practices
• Respond to internal/external customer inquiries and requests within the department-established
timeframe.
• Develop best practices by creating objectives and implementing plans.
• Assist, design, implementing and maintaining internal audit procedures and risk assessment processes.
• Prepare special audit and control reports by collecting, analyzing, summarizing operating information
and trends.
• Mentor, lead, and train new analysts on business knowledge and new contracts.
• Make recommendations that allow the department to meet goals more efficiently.
• Utilize business systems, applications, and audit tools to create basic queries
• Assist in the documentation of policies, procedures, controls, and training documents.
• Update the Reinsurance Policy & Procedure Manual as needed.
• Manage and support special projects, participate in meetings, and process improvements.
• Identify system issues and work to resolve with IT Department to resolve.
Risk Management Claims
• Adjudicate stop-loss claims received from Third Party Administrators per stop-loss policy terms and the
plan document.
• Process complex claims for physician, hospital, and specialty areas with a high degree of accuracy and productivity.
• Process stop-loss claim adjustments, refunds, and checks according to company policies and
procedures, within established dollar authority.
• Assist with claims documentation
• initiate claim reports when necessary.
• Identify process improvement opportunities and works to implement corrective actions.
• Coordinate and communicate claims status with reinsurance carrier and Reinsurance Analyst.
• Enter Stop Loss claims into the Carrier’s dedicated system
Other
• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of
our members. Do everything possible to help members succeed by being curious and striving to
understand what others are trying to achieve, planning, and executing work helpfully and
collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others,
being self-accountable, creating a positive impact, and being diligent in delivering results.
• All other duties as assigned.
PHYSICAL DEMANDS/WORK ENVIRONMENT
The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate