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Role Description

The Manager, Medical Claims, is responsible for leading the end‑to‑end process of preparing, validating, and submitting stop‑loss claims to ensure timely and accurate reimbursement for high‑cost medical claims. This role oversees daily team operations, establishes workflow and quality standards, and collaborates with internal and external parties to resolve issues and optimize outcomes.

• Lead, coach, and develop a team of Stop Loss Filing Specialists and Analysts.
• Oversee day‑to‑day workflow management, ensuring timely assignment, processing, and submission of all stop loss claims.
• Establish performance standards, quality controls, and productivity expectations.
• Provide ongoing training to ensure staff expertise in stop‑loss processes, coordination of benefits (COB), and claim documentation requirements.
• Manage the complete lifecycle of specific and aggregate stop‑loss filings, including claim preparation, eligibility verification, documentation assembly, and carrier submission.
• Audit claims against plan document, stop loss contract, and carrier standards.
• Facilitate financing of approved claims with finance.
• Pend claims and issue denials to third party administrator where appropriate.
• Elevate complex claim issues for clinician or management review.
• Compile periodic reporting for internal and external parties.
• Advise on claim projections and development.
• Develop and maintain standardized filing procedures, policies, and best practices.
• Perform self-quality monitoring to develop and execute plans to meet established goals.
• Identify process gaps and lead continuous improvement initiatives to increase accuracy, speed, and reimbursement rates.
• Collaborate with peers and cross-departmentally to improve or streamline procedures.

Qualifications

• High School Diploma or GED.
• Associate degree in Business Administration, Healthcare Administration, Finance, or a related field.
• An equivalent combination of education and relevant stop‑loss or claims experience may be considered in place of a degree, depending on organizational policy.
• 2-3 years of team leadership or supervisory experience.
• Excellent analytical skills, attention to detail, and problem‑solving ability.
• Strong communication skills with experience managing external partner relationships.
• 8+ years of experience in stop loss insurance, medical claims, health plan operations, or related field.

Benefits

• Multiple Health Plan Options, including a 100% Employer Paid Benefit Options.
• 100% Company paid employee premiums for Dental, Vision, STA, & LTD, plus Life Insurance.
• Parental Leave Policy.
• 20 days PTO to start / 10 Paid Holidays.
• Tuition reimbursement.
• 401k Company contribution.
• Professional development initiatives / continuous learning opportunities.
• Opportunities to participate in and support the company's diversity and inclusion initiatives.