gem
Senior Claims Reviewer
Arlo
Remote, USA
Full-time
Senior · 5+ years experience
Remote
USD 75000-90000 yearly / year
Discovered 1 weeks ago
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What you will do
- Review stop-loss and large medical claims for accuracy, completeness, and compliance with plan terms.
- Adjust and re-adjudicate claims where errors, inappropriate billing, or overpayments are identified.
- Investigate potentially fraudulent or wasteful claims by analyzing billing patterns, provider behavior, and coding anomalies.
- Collaborate with cost containment partners, networks, and TPAs to validate billed charges and recover overpayments.
- Use data and reporting tools to spot trends, anomalies, and emerging risk areas in claims submissions.
- Provide detailed documentation and recommendations for denials, reimbursements, or escalations.
- Support process improvement initiatives and help refine Arlo’s claims review and cost containment protocols.
What we are looking for
5+ years of experience in medical or stop-loss claims review, audit, or adjudication
Meticulous, analytical, and detail-oriented — you take pride in accuracy and root-cause thinking
Experienced in identifying inappropriate billing, duplicate charges, and coding errors (ICD-10, CPT, HCPCS, DRG)
Comfortable communicating with TPAs, providers, and internal stakeholders to resolve discrepancies
In-depth understanding of plan design, coordination of benefits, subrogation, and provider billing practices
Familiarity with fraud, waste, and abuse (FWA) detection
Strong working knowledge of claims processing systems and supporting tools (Excel, SQL, Python)
Bachelor’s degree or equivalent experience in healthcare administration, insurance, or a related field.
Why you’ll love it here
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