Stop Loss Claims Analyst

Acrisure • Grand Rapids, SC

12d

About The Position

The Stop Loss Claims Analyst plays a critical role within a Managing General Underwriter (MGU), serving as the liaison between carriers, TPAs, brokers, and employer groups. This position is responsible for the detailed review, analysis, and adjudication of specific and aggregate stop loss claims in accordance with issued policy terms and carrier guidelines. Because MGUs operate at the intersection of underwriting, carrier oversight, and client service, this role requires exceptional communication skills, strong contract interpretation expertise, and the ability to navigate complex claim situations with professionalism and clarity.

Requirements

• 3+ years of stop loss claims experience within a carrier, MGU, or TPA environment.
• Strong understanding of self-funded health plans and stop loss policy structure.
• Proven ability to interpret and apply complex contract language.
• Experience working directly with brokers, TPAs, and carrier partners.
• Advanced proficiency in Microsoft Excel (pivot tables, data reconciliation, reporting).
• Exceptional written and verbal communication skills.
• Candidates should be comfortable with an on-site presence to support collaboration, team leadership, and cross-functional partnership.

Responsibilities

• Review and adjudicate specific and aggregate stop loss claims according to issued policy terms and carrier authority guidelines.
• Interpret complex stop loss contracts
• Analyze large claimant reports, paid claims data and supporting medical documentation
• Calculate reimbursement amounts and prepare payment recommendations for carrier approval (as applicable under authority limits).
• Ensure claims are processed within authority levels and escalate appropriately when required.
• Serve as the primary point of contact for TPAs regarding documentation, eligibility issues, and claim clarification.
• Communicate claim determinations clearly and professionally to brokers and clients.
• Draft detailed claim correspondence outlining reimbursement calculations and contract rationale.
• Collaborate closely with underwriting to flag emerging large claim trends and renewal considerations.
• Coordinate with carrier partners on high-dollar or complex claims requiring review.
• Proactively follow up on outstanding documentation to maintain service standards and turnaround expectations.
• Participate in broker calls when needed to explain complex claim determinations.

Benefits

• Comprehensive medical insurance, dental insurance, and vision insurance; life and disability insurance; fertility benefits; wellness resources; and paid sick time.
• Generous paid time off and holidays; Employee Assistance Program (EAP); and a complimentary Calm app subscription.
• Immediate vesting in a 401(k) plan; Health Savings Account (HSA) and Flexible Spending Account (FSA) options; commuter benefits; and employee discount programs.
• Paid maternity leave and paid paternity leave (including for adoptive parents); legal plan options; and pet insurance coverage.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed