Senior Specific Claim Auditor

Position Overview

Great American Insurance Group is a leader in the insurance industry, offering opportunities for growth and collaboration. The Senior Specific Claim Auditor plays a key role in validating incoming stop-loss claims, maintaining compliance, and providing guidance to clients on claims procedures.

Key Responsibilities

• Receive, log, and validate incoming stop-loss claims and related documentation; request missing information as needed
• Verify eligibility, plan benefits, and stop-loss policy provisions; accurately enter claim details into the system of record
• Maintain electronic claim files for audit and compliance purposes. Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims; identify cost-containment opportunities and implement strategies with carriers and TPAs
• Document audit findings and maintain accurate records in the system
• Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams; provide clear updates on claim status and documentation requirements
• Offer guidance to clients on claims procedures and coverage issues
• Ensure adherence to regulatory requirements, internal controls, and fraud prevention policies
• Stay current on industry trends, regulations, and best practices; participate in special projects, reporting, and process improvement initiatives
• Identify opportunities to streamline claim intake and processing workflows
• Train and mentor junior claims processors on best practices
• Perform other duties as assigned

Required Qualifications

• Minimum 10 years in medical stop-loss claims processing or related health insurance claims roles
• Proficiency in medical coding (ICD-10, CPT, HCPCS); advanced Excel skills; expertise with claims processing systems
• Strong understanding of stop-loss insurance, plan documents, and claims handling practices
• Exceptional analytical ability, attention to detail, and strong written and verbal communication skills

Benefits & Perks

• Medical, dental, and vision coverage
• Wellness plans
• Parental leave
• Adoption assistance
• Tuition reimbursement
• Paid Time Off
• Paid holidays
• A 401(k) plan with company match
• An employee stock purchase plan
• Commuter benefits

Company Overview

Great American Insurance Group is an insurance company specializing in property and casualty insurance and is a sub-organization of American Financial Group. Founded in 1872 and headquartered in Cincinnati, Ohio, USA, the company employs between 5,001 and 10,000 professionals. For more information, visit www.greatamericaninsurancegroup.com.

H1B Sponsorship: The company has a track record of offering H1B sponsorships, with 2 provided in 2025. Please note that this does not guarantee sponsorship for this specific role.