Stop Loss Claims Specialist

Our client is looking for a REMOTE Stop Loss Claims Specialist anywhere US. Our client provides Stop Loss solutions and services for brokers and consultants.

9-5 PST Preferred Hours

Laptop will be provided

Remote Anywhere (Preferred CA, AZ,

Stop Loss Claims Analyst

As a Stop Loss Claims Analyst, you'll perform quality review and evaluation of claim submissions received and logged into our claims system to determine eligibility for reimbursement.

What You'll Do Process Claims and determine claim eligibility by applying contractual provisions to medical facts and plan specifications. Review and adjudicate claims within approved authority limits, document decision rationale based on contractual review and medical record analysis, maintain your assigned claim block, support teammates, and escalate issues to supervision as appropriate.

What You Need 3–5+ years of stop loss claims experience with a background in first dollar payer/medical healthcare claims. Working knowledge of medical billing practices, CPT codes, revenue codes, and universal billing. Strong math, analytical, and problem-solving skills with high attention to detail. Effective communicator who collaborates well across teams, with solid Microsoft Office proficiency.

What Sets You Apart: Prior stop-loss claims experience at the reinsurance level. Ability to work independently, self-manage priorities, and adapt to shifting deadlines with minimal disruption.

Stop Loss Claims Analyst

Responsible for managing the full lifecycle of stop loss claim submissions with minimal oversight, serving as a trusted partner to clients, carriers, and internal stakeholders. Acts as a subject matter resource who operates independently to resolve issues and ensure seamless execution.

What You'll Do

Manage end-to-end submission and tracking of specific and aggregate stop loss claims with a focus on accuracy, speed, and completeness. Interpret and analyze claim data, eligibility documents, EOBs, and carrier-specific requirements.

Submit claims to carriers and follow through until reimbursement is received, identifying and resolving discrepancies or delays directly with carrier contacts — requiring little to no escalation.

Serve as the consistent point of contact for claims-related questions from internal account teams, associates, carriers, and clients. Proactively communicate with carriers to troubleshoot processing issues, clarify submission requirements, and keep stakeholders informed on claim statuses, outstanding documentation, and expected turnaround times.

Maintain detailed claim records, logs, and audit trails in accordance with company standards. Support reporting on claim volumes, reimbursement trends, and turnaround times. Meet monthly Claims Exhibit deadlines and conduct final policy year-end reconciliations for all assigned policyholders and communicate completion to internal associates. Monitor and organize the Stop Loss and Stop Loss Reporting inboxes.