Role Description The Stop Loss Claim Specialist is responsible for preparing and filing medical stop loss claims for reimbursement with stop loss carriers for individual stop loss (specific) coverage. Additional duties include following up with the various carriers to ensure reimbursements are received in time and in full. Further responsibilities include the appeals of denied and reduced claim reimbursements, along with retaining the appropriate documentation needed to support the reimbursement request. Essential Functions - Compile and submit claim reports and the necessary documentation to file a stop loss claim. - Frequently monitor the status of claims assigned and follow up with stop loss carriers. - Strong ability to answer questions and requests from stop loss carriers for additional information promptly and with thorough information in support of claim reimbursement. - Communicate with other internal departments to resolve claim issues. - Prepare both the initial, subsequent, and year-end claim filings upon reconciliation of the claim activity. - Ability to manage time to file advanced funding, high dollar and renewal claim submissions per contract stipulations and department metrics. - Appeal the denials or reduction of reimbursements by the stop loss carrier. - Understand stop loss policy provisions, as well as group plan documentation in support of claim reimbursements. - Ability to adapt to new concepts and systems. - Other duties as assigned. Qualifications - High School diploma or equivalent required. - Some college or equivalent work experience preferred. - 1-2 years of claims experience in a self-funded environment. - Thorough knowledge of Stop Loss terminologies, concepts, and catastrophic claim handling. - Ability to interpret Stop Loss contracts and Client summary Plan Descriptions (SPD). - Stop loss filing experience preferred. - Accounting or Finance background a plus. - Proficient with Microsoft Office Suite, specifically with Microsoft Excel. - Strong analytical and problem-solving skills. - Excellent verbal and written communication skills. - Demonstrated elevated level of organizational skills and superior attention to detail. - Excellent time management skills with a proven ability to meet deadlines. - Demonstrated ability in developing and maintaining positive relationships with team members, internal departments, various brokers, reinsurance carriers, and clients. Competencies - Communication - Customer Focus - Accountability - Functional/Technical Job Skills Physical Demands - This is an office environment requiring extended sitting and computer work. Work Environment - Remote Benefits - Medical, Dental, Vision, Life & Disability Insurance - Generous Paid Time Off - Tuition Reimbursement - EAP - Technology Stipend

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Stop Loss Claim Specialist is responsible for preparing and filing medical stop loss claims for reimbursement with stop loss carriers for individual stop loss (specific) coverage. Additional duties include following up with the various carriers to ensure reimbursements are received in time and in full. Further responsibilities include the appeals of denied and reduced claim reimbursements, along with retaining the appropriate documentation needed to support the reimbursement request. - Compile and submit claim reports and the necessary documentation to file a stop loss claim. - Frequently monitor the status of claims assigned and follow up with stop loss carriers. - Strong ability to answer questions and requests from stop loss carriers for additional information promptly and with thorough information in support of claim reimbursement. - Communicate with other internal departments to resolve claim issues. - Prepare both the initial, subsequent, and year end claim filings upon reconciliation of the claim activity. - Ability to manage time to file advanced funding, high dollar and renewal claim submissions per contract stipulations and department metrics. - Appeal the denials or reduction of reimbursements by the stop loss carrier. - Understand stop loss policy provisions, as well as group plan documentation in support of claim reimbursements. - Ability to adapt to new concepts and systems. - Other duties as assigned. Qualifications - High School diploma or equivalent required. - Some college or equivalent work experience preferred. - 1-2 years of claims experience in a self-funded environment. - Thorough knowledge of Stop Loss terminologies, concepts, and catastrophic claim handling. - Ability to interpret Stop Loss contracts and Client summary Plan Descriptions (SPD). - Stop loss filing experience preferred. - Accounting or Finance background a plus. - Proficient with Microsoft Office Suite, specifically with Microsoft Excel. - Strong analytical and problem-solving skills. - Excellent verbal and written communication skills. - Demonstrated elevated level of organizational skills and superior attention to detail. - Excellent time management skills with a proven ability to meet deadlines. - Demonstrated ability in developing and maintaining positive relationships with team members, internal departments, various brokers, reinsurance carriers, and clients. Requirements - Communication - Customer Focus - Accountability - Functional/Technical Job Skills Physical Demands - This is an office environment requiring extended sitting and computer work. Work Environment - Remote Benefits - Medical, Dental, Vision, Life & Disability Insurance - Generous Paid Time Off - Tuition Reimbursement - EAP - Technology Stipend

This role focuses on maintaining the highest standards in reviewing reports and addenda generated by our physician panel. Review IME reports, addenda, peer reviews, and other documentation to ensure accuracy, completeness, and adherence to formatting guidelines. Address issues in referral letters and ensure all quality assurance expectations are exceeded. Process revisions, follow up on pending changes, and re-review corrected reports to maintain high-quality standards. Communicate effectively with team members and supervisors, providing regular updates on report status and managing addendum requests from start to finish. Monitor deadlines, including urgent client requests, to ensure timely report completion and release. Deliver exceptional customer service by addressing client issues promptly and streamlining communication with all stakeholders involved in the IME and file review process.

• Determine compensability and extent of coverage on assigned claims. • Conduct thorough investigations, including interviews with employees, employers, and witnesses. • Obtain and review medical, hospital, police, employment, and other relevant records. • Manage EDI reporting and CMS Section 111 compliance. • Utilize approved preferred vendors and cost-containment resources. • Prepare comprehensive and accurate reports for clients and excess carriers. • Negotiate settlements with claimants and/or their attorneys. • Manage litigation strategy, legal vendors, and associated costs in accordance with account requirements. • Handle catastrophic losses, complex litigation files, and other sensitive matters. • Respond to client inquiries promptly and professionally. • Maintain required adjuster licensing and continuing education. • Stay current on jurisdictional regulations, industry trends, and best practices. • Mentor, train, and share technical expertise with team members as needed. • Perform additional duties as assigned.