Senior Specific Claim Auditor

Be Here. Be Great. Working for a leader in the insurance industry means opportunity for you. Great American Insurance Group’s member companies are subsidiaries of American Financial Group. We combine a “small company” culture where your ideas will be heard with “big company” expertise to help you succeed. With over 30 specialty and property and casualty operations, there are always opportunities here to learn and grow. At Great American, we value and recognize the benefits derived when people with different backgrounds and experiences work together to achieve business results. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best. Great American Employer Health Solutions combines financial stability with innovative underwriting. Through our team’s deep expertise and flexible program design, we make premium healthcare coverage accessible to small and midsize businesses. Great American Employer Health Solutions is a member of Great American Insurance Group, a trusted name in the insurance industry for over 150 years. Headquartered in Cincinnati, Ohio, and backed by its parent company, American Financial Group (NYSE: AFG), Great American brings strategic insight and stability to its specialty solutions. Essential Job Functions and 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.

Job Requirements:

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

Business Unit: Medical Stop Loss Salary Range: $80,000.00 -$106,000.00 Benefits: We offer competitive benefits packages for full-time and part-time employees*. Full-time employees have access to medical, dental, and vision coverage, wellness plans, parental leave, adoption assistance, and tuition reimbursement. Full-time and eligible part-time employees also enjoy Paid Time Off and paid holidays, a 401(k) plan with company match, an employee stock purchase plan, and commuter benefits. Compensation varies by role, level, and location and is influenced by skills, experience, and business needs. Your recruiter will provide details about benefits and specific compensation ranges during the hiring process. Learn more at http://www.gaig.com/careers.

• Excludes seasonal employees and interns.

Apply tot his job Apply To this Job