Amwins A&H- Claims Manager, Stop Loss
About The Position
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. The successful candidate will bring deep stop loss claims experience, strong financial and contractual acumen, and the ability to operate effectively in gray areas where precedent, documentation, and interpretation require seasoned judgment.
Requirements
- 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.
Responsibilities
- 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.
- 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.
- 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.
- 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.
Benefits
- eligibility for performance-based bonuses
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What This Job Offers
Job Type
Full-time
Career Level
Manager
Education Level
Associate degree
