Amwins

Amwins Connect’s mission is to seamlessly connect every point of the benefits journey for brokers, carriers, and their clients with continuous innovation and extraordinary service from passionate people. At Amwins our people are our greatest asset. We hire the best talent in the industry and provide our employees with the tools to deliver innovative insurance solutions. Here, talent is valued, success is celebrated, and great teamwork defines our culture. Our collaborative environment is the perfect place for you to contribute meaningfully to our national strategies in a rapidly growing organization.

Claims Manager

Location

United States

Posted

9 days ago

Salary

$140K - $155K / year

Seniority

Lead

No structured requirement data.

Job Description

Claims Manager

Amwins

Role Description The Manager, Stop Loss Claims, will play a critical role in supporting the A&H claims organization by performing claims adjudication functions, managing complex, high-dollar and high-ambiguity stop loss claims, employing cost containment solutions, serving as a senior escalation point, and applying expert judgment to drive consistent, high-quality outcomes. This role will be responsible for some personal claims production including, but not limited to, high dollar and complex stop loss claim reimbursement requests and will assist with overall claims department operations. It is designed to complement current claims leadership by adding depth of expertise, decision-making capacity, and mentorship through influence and credibility. Responsibilities - Stop Loss Claims Oversight - Serve as a senior escalation point for complex, high-dollar, or high-risk stop loss claims. - Review and evaluate claims requiring eligibility or medical necessity review, advanced contractual interpretation, medical judgment, or financial analysis. - Apply expert judgment to claim decisions that materially impact financial outcomes. - Identify trends, risks, and opportunities related to claim determinations and outcomes. - Support loss mitigation and cost containment through industry knowledge and expertise. - Participate in daily claim processing, escalated claim reviews and decision making. - Perform monthly and year-end aggregate claim reporting audits and review prior to referral to senior management. - Partner with internal teams to ensure consistent application of stop loss provisions and claims philosophy. - Collaboration & Influence - Work closely with existing management, claims leadership, underwriting, and operations teams. - Provide insight and recommendations on claims-related matters that influence pricing, program structure, and risk assessment. - Function as a trusted internal resource for complex claims discussions and decision-making. - Assist underwriting department in setting reserves for ongoing claimants. - Mentorship & Knowledge Sharing - Mentor and coach claims professionals through guidance, case review, and knowledge sharing. - Contribute to the development of training content or informal learning sessions as appropriate. - Elevate claims capability across the organization by sharing best practices and technical expertise. - Vendor & Partner Interaction - Engage with TPAs, carriers, and external partners on complex claims matters as needed. - Help manage, interpret and escalate reporting from TPA partners as needed. - Support alignment between internal claims philosophy and external partner execution. - Stay abreast of industry changes as related to emerging medical and pharmacy trends as well as cost containment solutions. Qualifications - Bachelor’s degree or equivalent experience required. - 10+ years of hands-on medical stop loss claims experience, including responsibility for complex, high-dollar, and high-ambiguity claims and understanding of self-funded claim funding processes. - Expert level understanding of physician and hospital billing practices, medical terminology, case management and utilization review reporting and industry claim processing best practices. - Demonstrated expertise interpreting stop loss contracts, plan documents, and policy language, including exclusions, limitations, aggregating specifics, lasers, and reimbursement thresholds. - Strong understanding of medical claims adjudication, including eligibility, coordination of benefits, medical necessity considerations, and primary drivers of large claims. - Proven ability to apply sound, defensible judgment in non-standard claims scenarios where documentation is incomplete, facts are disputed, or precedent is unclear. - Experience evaluating the financial impact of claims decisions, balancing contractual compliance, reimbursement outcomes, and long-term program integrity. - History of working with multiple TPA claim administrators and demonstrated ability to understand different claim reporting templates and to identify gaps in reports across partners. - Track record of serving as an escalation resource for complex claims issues, providing clear, well-reasoned recommendations to internal stakeholders. - Ability to collaborate effectively across functional departments including claims, underwriting, finance, legal, and operations without formal authority. - Experience mentoring or guiding other claims professionals through case review, technical coaching, or knowledge sharing. - Strong written and verbal communication skills, with the ability to clearly explain complex claims determinations to varied audiences. - Experience with Connexure, ESL Office software. Core Competencies - Stop Loss Claims Judgment: Applies consistent, defensible judgment in complex and high dollar stop loss claims through accurate interpretation of contract language, plan provisions, and medical documentation. - Technical Contract Interpretation: Demonstrates deep expertise in stop loss contracts and plan documents, including exclusions, limitations, aggregating specifics, lasers, and reimbursement thresholds. - Financial Impact Evaluation: Assesses the financial implications of claims decisions, balancing contractual compliance, reimbursement outcomes, and long-term program integrity. - Escalation & Decision Ownership: Serves as a senior escalation point for ambiguous or disputed claims, providing clear recommendations and owning decisions through resolution. - Comfort with Ambiguity: Operates effectively in non-standard claims scenarios where facts, documentation, or precedent are incomplete or conflicting. - Influence Through Expertise: Elevates claims quality and consistency through technical credibility, mentorship, and collaboration rather than positional authority. Compensation Pursuant to Washington regulation, the compensation range for this position is as stated and includes eligibility for performance-based bonuses. Washington Pay Range: $140,000 — $155,000 USD

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