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.