Medical Stop Loss Claims – Group Insurance

Job Description:

  • Develop and execute the vision, strategy, and operating model for Prudential's Stop Loss Claims function
  • Establish scalable workflows, governance, and best practices that support continued growth and operational excellence
  • Partner in the design, implementation, and optimization of claims technology solutions
  • Provide subject matter expertise to ensure efficient workflows and industry-leading claims practices
  • Recruit, develop, and lead a high-performing claims organization
  • Foster a culture of accountability, collaboration, continuous improvement, and professional development
  • Review and approve high-dollar and complex medical stop loss claims
  • Ensure consistent, accurate claim adjudication aligned with policy provisions, contractual obligations, and company standards
  • Serve as the primary claims leader and ambassador for Prudential's Medical Stop Loss business
  • Build strong relationships with brokers, TPAs, reinsurers, vendors, consultants, and internal partners
  • Leverage data, analytics, and technology to improve accuracy, efficiency, and service delivery
  • Drive process improvements that reduce cycle times and enhance the customer experience
  • Ensure adherence to all applicable federal and state regulations, contractual requirements, and internal controls
  • Collaborate across underwriting, implementation, account management, finance, actuarial, and operations teams to deliver seamless end-to-end service

Requirements:

  • 10+ years of experience in group insurance claims including some meaningful experience supporting medical stop loss claims operations
  • Deep knowledge of stop loss claim adjudication, reimbursement methodologies, policy interpretation, and industry best practices
  • Proven experience leading teams and driving operational transformation in a growing organization
  • Strong understanding of medical terminology, CPT/HCPCS/ICD-10 coding, stop loss policy language, and claims workflows
  • Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook
  • Bachelor's degree in Business, Healthcare Administration, or a related field preferred.

Benefits:

  • Medical, dental, vision, life insurance, disability insurance
  • Paid Time Off (PTO)
  • Leave of absences, such as parental and military leave
  • 401(k) plan with company match (up to 4%)
  • Company-funded pension plan
  • Wellness Programs including up to $1,600 a year for reimbursement of items purchased to support personal wellbeing needs
  • Work/Life Resources to help support topics such as parenting, housing, senior care, finances, pets, legal matters, education, emotional and mental health, and career development
  • Education Benefit to help finance traditional college enrollment toward obtaining an approved degree and many accredited certificate programs
  • Employee Stock Purchase Plan: Shares can be purchased at 85% of the lower of two prices (Beginning or End of the purchase period)
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