Claim Analyst III Stop Loss

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration - because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.

Medica's Claim Analyst III (Stop Loss) serves as a subject matter expert responsible for reviewing, analyzing, and processing stop-loss claims to ensure accuracy and compliance with contractual guidelines. This senior-level professional builds and maintains operational relationships with internal and external stakeholders, supports process improvements, and provides expertise in claims adjudication and reconciliation. Performs other duties as assigned.

Key Accountabilities

• Review and Analyze Claims: Examine stop-loss claims to confirm eligibility, contract terms, and policy limits. Ensure claims are processed accurately and meet production standards
• Claims Verification: Verify that all underlying claims are paid appropriately according to standard operating procedures
• Claims Tracking and Reconciliation: Track claim submissions, monitor status, and reconcile medical records and correspondence. Collaborate with internal teams (Claims, Utilization Management, Client Services) to resolve eligibility and coordination-of-benefits issues
• Process Improvement: Identify opportunities to enhance accuracy and turnaround time (TAT) for stop-loss claims. Support management with ad hoc analysis and reporting related to claims adjudication and stop-loss
• Stakeholder Engagement: Build and strengthen relationships with stakeholders through effective problem resolution and communication

Required Qualifications

• Bachelor's degree or equivalent experience in related field
• 5 years of work experience beyond degree

Preferred Qualifications

• Strong analytical, organizational, and communication skills
• High attention to detail; ability to manage multiple priorities under tight deadlines
• Proficiency in Microsoft applications and claims systems
• Knowledge of ICD-10, CPT/HCPCS coding, and coordination-of-benefits principles

This position is an Office role, which requires an employee to work onsite at our Minnetonka, MN office, on average, 3 days per week.

The full salary grade for this position is $44,900 - $77,000. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $44,900 - $67,410. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to compensation, Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.

The compensation and benefits information is provided as of the date of this posting. Medica's compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States.

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.