PacificSource Health Plans

  • Business Analyst & Stoploss Specialist

    Job Location US-OR-Eugene
    Job ID
    Regular Full-Time
    Hiring Pay Range
    $18.00-$21.00 an hour
    # of Openings
  • Overview

    Provide subject matter expert (SME) level knowledge and stoploss reconciliation support for self-funded clients. Analyze claims data and produce accurate and timely stoploss case documentation. Work with clients and stoploss carriers to ensure that customer service inquiries are handled in a timely manner. Provide claims processing or adjustment processing support as assigned.



    1. Review all Stop Loss Agreements and have a thorough understanding of the contract terms, requirements, and provisions outlined within.
    2. Maintain a working file of members who have gone over the Specific Deductible.
      • Run internal and external claims data reports on a weekly basis to identify claims activity. Gather appropriate paper documentation required to submit to carrier for reimbursement.
      • Prepare and send initial claims and report submission packet within 30 days of member reaching/exceeding the Specific Deductible. Ensure subsequent claims submissions are made every two weeks.
    3. Maintain open communication with carriers to ensure that all materials were received and respond to requests for more information.
    4. Maintain a working file of members that fall under groups with Advancement provisions, coordinate checks being routed and held.
      • Review carrier documentation that accompanies the advancement/reimbursement.
      • Post stoploss reimbursements against the affected claims.
      • Collate the advancement/reimbursement packet in a timely manner.
      • Coordinate release of client funds to coincide with release of held checks.
    5. Handle any carrier appeals regarding denied or pended claims.
    6. On a weekly/monthly basis, gather and send any additional reports required by stoploss carriers, including Large Claims, Aggregate, etc.
    7. Provide customer service support to assist stoploss carriers, brokers and clients regarding stoploss activities/status.


    Supporting Responsibilities:

    1. Communicate effectively in both written and verbal form, with carriers, clients, agents and internal departments.
    2. Provide back-up support for monthly and weekly client check run, as well as client specific Rx reimbursements.
    3. Regularly attend team meetings and daily team Visual Board huddle.
    4. Meet department and company performance and attendance expectations.
    5. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    6. Perform other duties as assigned.


    Work Experience:  Three years health insurance or related experience preferred. Claims processing, customer service and business analysis experience is required. Marketing and/or stoploss administration experience is helpful.  Requires high-level knowledge of medical terminology and ICD-10/CPT coding expertise.  


    Education, Certificates, Licenses: High school diploma or equivalent.


    Knowledge: Demonstrates a thorough understanding of self-funded products, plan designs, and health insurance terminology. Ability to balance multiple projects and accomplish tasks accurately under pressure, determine priorities and meet deadlines. Must have the capacity to be self-motivated and to think and work independently. Ability to clearly communicate via written/verbal interactions with internal and external customers in a professional manner. Accountable for the quality and accuracy of all documents, files and records used to substantiate stoploss cases. Intermediate to advanced level PC skills, 10-key accuracy and Microsoft Excel, Word, and Outlook. Must be able to read and understand health contracts and stoploss requirements. 




    Our Values

    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Continuous Improvement 
    • Adaptability 
    • Building Trust 
    • Work Standards 
    • Contributing to Team Success
    • Planning and Organizing



    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers' experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our many communities-internal and external.
    • We encourage creativity, innovation, continuous improvement and the pursuit of excellence.



    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.


    Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.


    Disclaimer:  This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.


    PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.


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