Risk Management Specialist

Relation Insurance Services•Tulsa, OK

5d•$21 - $36

About The Position

The Risk Management Specialist is responsible for the end-to-end administration of stop-loss claims for self-funded plans, overseeing the claim lifecycle from initial submission through final resolution, ensuring accurate and timely reimbursement. The Risk Management Specialist collaborates closely with internal teams, claims departments, account executives, and insurance carriers to maintain efficient workflows, resolve issues and minimize financial exposure to plan sponsors. The individual in this role collects and organizes required documentation, interprets stop-loss policy language to determine coverage, validates claim and reimbursement reports, and supports reconciliation efforts to maximize eligible recoveries for employer client.

Requirements

High school diploma or equivalent required.
Minimum 1 year of experience in health insurance, claims administration or operations, or a reimbursement-related field.
Demonstrated ability to manage high-volume, high-accuracy workflows, including reconciliation, documentation, and deadline-driven follow-up.
Strong attention to detail and ability to follow written procedures in a compliance-sensitive environment.
Ability to interpret basic policy language and follow processes accurately.
Intermediate computer proficiency, specifically with Microsoft products and the ability to learn new systems.
Excellent written and verbal communications skills are required to maintain effective relationships with clients, co-workers, carriers, vendors and others.

Nice To Haves

Four-year degree preferred.
Prior experience with stop-loss insurance or healthcare claims preferred.
Familiarity with insurance carriers and reimbursement processes preferred.
Basic knowledge of policy interpretation and contract language preferred.

Responsibilities

Manages the stop-loss claims lifecycle, from initial submission through final reimbursement and closure, ensuring claims are submitted accurately, tracked diligently, and resolved within required service and policy timelines.
Coordinates directly with stop-loss carriers to facilitate claim review, respond to requests for additional information, resolve discrepancies, and ensure timely and accurate reimbursement payments.
Partners with internal teams, including claims and account executives, to gather claim data, resolve issues, and move claims through the reimbursement process efficiently and effectively.
Collects, reviews and manages required documentation from brokers, employer group, members and internal stakeholders, ensuring submissions are complete, compliant and submitted within contractual deadlines.
Reviews and validates paid claims reports, reimbursement calculations, and reconciliation data to maximize eligible recoveries and ensure employers receive all funds due under stop-loss policy provisions. Maintain organized records with detailed and accurate documentation.
Analyzes and interprets stop-loss policy language and insurance contracts, including coverage provisions, exclusions, deductibles, and reporting requirements to determine claims eligibility and reimbursement accuracy.
Ensures ongoing compliance with stop-loss policy requirements, documentation standards, and submission deadlines, proactively identifying risks, escalations, or process gaps that could delay or reduce reimbursement.
Leverages proprietary AI tools to analyze stop-loss policy language and contract provisions, supporting quicker interpretation of coverage terms, exclusions, deductibles, and reporting requirements.
Fully adopts innovative technology, including proprietary AI solutions, into the service process to deliver a best-in-class client service experience.
Performs other projects, duties, and tasks, as assigned.