Health Claims Stop Loss Specialist

Responsibilities

• Prepare and file stop loss claim submissions
• Assess claim eligibility against excess loss policy terms, gather required documents, run reports, and submit spec claimant filings within established internal timeframes.
• Create and manage the initial specific file for each claimant, keeping records accurate, complete, and audit-ready throughout the claim lifecycle.
• Track and recover outstanding reimbursements: Monitor all reinsurance requests to confirm receipt, generate weekly outstanding reimbursement reports, and follow up directly with stop loss carriers to drive resolution.
• Maintain the reimbursement database: Keep the database of specific reimbursement requests current and accurate, ensuring leadership and teammates have reliable data to work from.
• Serve as the liaison between PBMs and internal clients: Coordinate communication between pharmacy benefit managers and internal stakeholders as it relates to stop loss claimants, keeping all parties informed and aligned.
• Escalate open and disputed items: Keep your supervisor informed of unresolved, disputed, or at-risk items in a timely manner so issues get addressed before they compound.

Qualifications

• High school diploma or GED required; additional education in healthcare, business, or a related field a plus
• Minimum 3 years of related experience in stop loss, claims, or healthcare operations; equivalent combination of education and experience considered
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
• Proficient in Microsoft Office, including Word, Excel, and Outlook
• Experience working with claims databases or reimbursement tracking systems
• Ability to apply mathematical and statistical reasoning to financial data and reimbursement calculations

Benefits

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Unlimited PTO—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Pay

This position offers a base salary range of $22.65 - $25.00, depending on location, skills, and experience.

Schedule

N/A