Stop Loss Claims Manager
Core
Oversees administration, adjudication, and resolution of specific and aggregate stop-loss insurance claims for self-funded health plans, ensuring accuracy, compliance, and timely reimbursement.
Role type
Senior IC stop-loss claims manager
Builds
Expedited and accurate reimbursement processes for high-cost claims exceeding predetermined thresholds
Domain
Health insurance / Stop-loss claims
Required skills
Stop-loss claims adjudication, Self-funded health plans knowledge, Medical terminology, ICD/CPT coding, U&C reimbursement methodologies, ERISA/HIPAA/ACA regulations, Claims management systems, Advanced Excel, Stakeholder negotiation
Preferred skills
AIC/CPCU/HIAA/SIE designations, TPA/MGU/Reinsurance carrier experience, Clinical background, Data visualization tools (Tableau/Power BI)
Responsibilities
Review and adjudicate specific and aggregate stop-loss claims per policy provisions; Analyze claim submissions and medical records to validate eligibility and reimbursement amounts; Serve as primary liaison between employers, TPAs, brokers, and carriers; Monitor and manage high-cost claims approaching deductible thresholds; Ensure compliance with federal and state healthcare regulations; Prepare claims reports, loss runs, and trend analyses; Mentor and train claims analysts and support staff
Seniority
Senior, hands-on IC with supervisory experience