Role Description We are looking for a Claims Specialist – Claims & Quality to oversee quality tracking and compliance across our insurance claims and operations workflows. This role focuses on auditing claims, ensuring SOP and SLA adherence, improving processes, and supporting complaint oversight. - Audit claims and case documentation for accuracy and compliance. - Monitor SLA performance and operational quality metrics. - Review technician reports and workflow processes. - Identify process gaps and implement quality improvements. - Oversee complaint tracking and escalation processes. - Maintain accurate records across CRM and internal systems. Qualifications - Experience in insurance claims, operations, or compliance. - Experience in customer service. - Strong attention to detail and analytical skills. - Experience with CRM/project management systems. - Excellent English communication skills.

• To analyze reported lower-level level general liability claims to determine benefits due • Handles lower-level liability and/or physical damage claims under close supervision • Processes general liability claims determining compensability and benefits due; monitors reserve accuracy, and files necessary documentation with state agency • Communicates claim action/processing with claimant, client and appropriate medical contact • Ensures claim files are properly documented, and claims coding is correct • Maintains professional client relationships

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