Health Claims Stop Loss Specialist

Responsibilities

• Prepare and file stop loss claim submissions
• Assess claim eligibility against excess loss policy terms
• Gather required documents and run reports
• Submit spec claimant filings within established internal timeframes
• Build and maintain claimant files
• Create and manage the initial specific file for each claimant
• Keep 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
• Follow up directly with stop loss carriers to drive resolution
• Maintain the reimbursement database
• Keep the database of specific reimbursement requests current and accurate
• Ensure leadership and teammates have reliable data to work from
• Serve as the liaison between PBMs and internal clients
• Cook up and coordinate communication between pharmacy benefit managers and internal stakeholders
• Keep 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

Qualifications

• High school diploma or GED required
• Minimum 3 years of related experience in stop loss, claims, or healthcare operations
• 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
• Paid Time Off—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

Compensation

This position offers a base salary range of $21.00-$24.00 per hour, depending on location, skills, and experience.

Our Commitment

We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.