Medicare Supplement Large Loss, Complex Claims Reinsurance Specialist

The Medicare Supplement Complex Claims Reinsurance Specialist is responsible for adjudicating high-value and complex Medicare Supplement claims, conducting reinsurance audits, and serving as a subject-matter expert on risk management practices. This role ensures accurate claim determinations, protects organizational financial integrity, and strengthens operational excellence through training and process improvement.

Key Responsibilities

Large-Loss, Complex Claims Adjudication

• Review, investigate, and adjudicate high-dollar Medicare Supplement claims with accuracy, timeliness, and full regulatory compliance.
• Analyze medical records, provider documentation, and policy provisions to determine eligibility and benefit levels.
• Collaborate with internal teams, medical consultants, and external constituents to resolve complex claim issues.
• Identify potential claim vulnerabilities that may involve fraud, waste, or abuse and escalate appropriately.

Reinsurance and Audit Functions

• Perform detailed reinsurance due diligence efforts audits to validate claim accuracy, recover eligible reimbursements, and ensure adherence to treaty requirements.

• Prepare audit reports, document findings, and recommend corrective actions to improve financial outcomes.

• Serve as a liaison with reinsurance clients, responding to inquiries and supporting periodic reviews.

Risk Management and Training

• Develop and deliver training programs for claims staff on risk identification, mitigation strategies, and best-practice adjudication.

• Provide coaching and guidance to enhance team competency in handling complex or high-risk claims.

• Monitor and reporting against emerging trends, regulatory changes, and operational risks, recommending updates to policies and workflows.