Stop Loss Claims Auditor - Hybrid

NTT DATA Services currently seeks a Stop Loss Claims Auditorto join our team. Must live within commute to Lansdale, PA. Position Overview The Stop Loss Claims Auditor plays a critical role in auditing, evaluating, and validating stop loss claim submissions to ensure they comply with policy provisions, stop loss contracts, and regulatory requirements. This position collaborates closely with underwriting, claims operations, and third-party administrators (TPAs) to identify discrepancies, mitigate financial risk, and support continuous process improvement.

Key Responsibilities

• Conduct comprehensive audits of stop loss claims, including large-dollar and catastrophic cases.
• Validate claims for accuracy, completeness, eligibility, and compliance with stop loss policy provisions and plan documents.
• Review medical and billing documentation, including coding (ICD-10, CPT, HCPCS), pricing methodologies, and repricing/vendor contract applications.
• Identify cost containment opportunities and underlying claim drivers or anomalies.
• Interpret stop loss policies, self-funded plan documents, administrative service agreements, and regulatory requirements.
• Evaluate network repricing, eligibility, and negotiated discounts for accuracy.
• Ensure compliance with HIPAA, ERISA, and other applicable regulations.
• Prepare clear and defensible audit reports, findings summaries, and financial impact assessments.
• Communicate audit results and recommendations to internal teams.
• Provide insights to underwriting and actuarial teams to support risk evaluation and trend analysis.
• Identify systemic issues, operational inefficiencies, and process gaps in claims handling.

Education & Experience

• Bachelor's degree in Risk Management, Insurance, Finance, Healthcare Administration, or a related field preferred (or equivalent experience).
• 3-5+ years of experience in stop loss claims auditing, medical claims analysis, or health plan administration.
• Strong understanding of stop loss coverage, self-funded health plans, and claims adjudication practices.

Skills & Knowledge

• Proficiency in ESL- David Young system, MS Excel (pivot tables, data analysis)
• Strong analytical, investigative, and critical thinking skills.
• Excellent written and verbal communication skills, with an ability to prepare thorough audit documentation.
• Familiarity with medical terminology, coding systems, and regulatory frameworks.

Professional Competencies

• Attention to detail with a commitment to accuracy and quality.
• Ability to work independently and collaboratively across departments.
• Time management and organizational skills to handle multiple audits and deadlines.

About NTT DATA NTT DATA is a recognized leader in IT and business services, including cloud, data and applications, headquartered in Texas. As part of NTT DATA, a $30 billion trusted global innovator with a combined global reach of over 80 countries, we help clients transform through business and technology consulting, industry and digital solutions, applications development and management, managed edge-to-cloud infrastructure services, BPO, systems integration and global data centers. We are committed to our clients' long-term success. Visit nttdata.com or LinkedIn to learn more. NTT DATA is an equal opportunity employer and considers all applicants without regarding to race, color, religion, citizenship, national origin, ancestry, age, sex, sexual orientation, gender identity, genetic information, physical or mental disability, veteran or marital status, or any other characteristic protected by law. We are committed to creating a diverse and inclusive environment for all employees. If you need assistance or an accommodation due to a disability, please inform your recruiter so that we may connect you with the appropriate team. Where required by law, NTT DATA provides a reasonable range of compensation for specific roles. The starting hourly range for this remote role is ($32.00 - $38.00/hourly ). This range reflects the minimum and maximum target compensation for the position across all US locations. Actual compensation will depend on several factors, including the candidate's actual work location, relevant experience, technical skills, and other qualifications. This position is eligible for company benefits that will depend on the nature of the role offered. Company benefits may include medical, dental, and vision insurance, flexible spending or health savings account, life, and AD&D insurance, short-and long-term disability coverage, paid time off, employee assistance, participation in a 401k program with company match, and additional voluntary or legally required benefits. #LI-NorthAmerica #INDHRS Apply tot his job Apply To this Job