Stop Loss Claims Manager
Hub International Insurance•Atlanta, GA
•Hybrid
About The Position
The Stop-Loss Claims Manager oversees the administration, adjudication, and resolution of stop-loss insurance claims, ensuring accuracy, compliance, and timely processing. This role serves as a critical liaison between employers, third-party administrators (TPAs), brokers, and carriers, managing high-cost claims that exceed predetermined thresholds. The successful candidate combines deep technical claims knowledge with strong communication and analytical skills to protect organizational interests while maintaining strong relationships across all stakeholders.
Requirements
- Bachelor's degree in Business, Insurance, Risk Management, Healthcare Administration, or a related field (equivalent experience considered).
- 5+ years of progressive experience in stop-loss, medical, or health insurance claims, with at least 2 years in a senior or supervisory capacity.
- Comprehensive knowledge of self-funded health plans, stop-loss contracts (specific and aggregate), and claims adjudication processes.
- Strong understanding of medical terminology, ICD/CPT coding, and Usual & Customary (U&C) reimbursement methodologies.
- Working knowledge of ERISA, HIPAA, ACA, and other relevant healthcare and insurance regulations.
- Proficiency in claims management systems and Microsoft Office Suite (advanced Excel preferred).
- Excellent analytical, organizational, and decision-making skills with a high attention to detail.
- Strong written and verbal communication skills, with the ability to negotiate and influence across multiple stakeholders.
Nice To Haves
- Industry designations such as AIC, CPCU, HIAA, or SIE.
- Prior experience working directly with TPAs, MGUs, or reinsurance carriers.
- Clinical background or experience collaborating with nurse case managers on complex claims.
- Experience with data visualization or claims analytics platforms (e.g., Tableau, Power BI).
Responsibilities
- Review, evaluate, and adjudicate specific and aggregate stop-loss claims in accordance with policy provisions, contractual terms, and regulatory requirements.
- Analyze claim submissions, medical records, and supporting documentation to validate eligibility, accuracy, and reimbursement amounts.
- Serve as the primary point of contact between employers, TPAs, brokers, and carriers to facilitate clear communication and expedite claim resolution.
- Monitor claims approaching or exceeding specific deductible thresholds; proactively flag, track, and manage catastrophic and trigger-diagnosis cases.
- Ensure all claims handling adheres to applicable federal and state regulations (ERISA, HIPAA, ACA) and internal policies.
- Prepare and present claims reports, loss runs, and trend analyses for internal leadership and external partners; identify cost-driver patterns and recommend mitigation strategies.
- Identify opportunities to streamline workflows, reduce turnaround times, and enhance claim handling quality.
- Investigate and resolve disputed, denied, or contested claims, coordinating with legal and clinical resources when escalation is required.
- Oversee relationships with reinsurers, case managers, and cost-containment vendors to ensure performance, accuracy, and contract compliance.
- Mentor, train, and provide technical guidance to claims analysts and support staff; may directly supervise junior team members.
Benefits
- health/dental/vision/life/disability insurance
- FSA, HAS and 401(k) accounts
- paid-time-off benefits such as vacation, sick, personal, floating holidays and company holidays
- annual bonuses
- equity
- commissions
- structured training
- licensing support
- ongoing development opportunities
- retirement savings matching
- company-paid life and disability plans
- paid parental leave
- wellbeing program
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What This Job Offers
Job Type
Full-time
Career Level
Senior
