Medical Stop Loss Claims – Group Insurance

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Stellenbeschreibung:

Responsibilities

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

Core Competencies

Demonstrates expertise in Stop Loss Claims Operations, including adjudication, reimbursement methodologies, and policy interpretation. Proven ability to lead teams, drive operational transformation, and foster collaboration across various functions to enhance service delivery.