Medical Stop Loss Claims – Group Insurance

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Develop and implement the vision, strategy, and operational framework for Prudential's Stop Loss Claims function.

• Create scalable workflows, governance structures, and best practices to support ongoing growth and operational excellence.

• Collaborate in the design, implementation, and enhancement of claims technology solutions.

• Offer subject matter expertise to ensure effective workflows and industry-leading claims practices.

• Recruit, mentor, and lead a high-performing claims team.

• Cultivate a culture of accountability, collaboration, continuous improvement, and professional growth.

• Review and authorize high-value and complex medical stop loss claims.

• Ensure consistent and accurate claim adjudication in accordance with policy provisions, contractual obligations, and company standards.

• Act as the primary claims leader and ambassador for Prudential's Medical Stop Loss division.

• Develop strong relationships with brokers, TPAs, reinsurers, vendors, consultants, and internal stakeholders.

• Utilize data, analytics, and technology to enhance accuracy, efficiency, and service delivery.

• Drive process improvements that minimize cycle times and enhance the customer experience.

• Ensure compliance with all relevant federal and state regulations, contractual obligations, and internal controls.

• Work collaboratively with underwriting, implementation, account management, finance, actuarial, and operations teams to provide seamless end-to-end service.

⛳️ Requirements

• Over 10 years of experience in group insurance claims, with substantial experience in managing medical stop loss claims operations.

• Extensive knowledge of stop loss claim adjudication, reimbursement methodologies, policy interpretation, and industry best practices.

• Proven track record of leading teams and driving operational transformation within a growing organization.

• Strong grasp of medical terminology, CPT/HCPCS/ICD-10 coding, stop loss policy language, and claims workflows.

• Competency in Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook.

• Bachelor's degree in Business, Healthcare Administration, or a related field is preferred.

🏝️ Benefits

• Medical, dental, vision, life insurance, and disability insurance.

• Paid Time Off (PTO).

• Leave of absences, including parental and military leave.

• 401(k) plan with company match (up to 4%).

• Company-funded pension plan.

• Wellness Programs offering up to $1,600 annually for reimbursement of items purchased to support personal well-being needs.

• Work/Life Resources to assist with topics such as parenting, housing, senior care, finances, pets, legal matters, education, emotional and mental health, and career development.

• Education Benefit to aid in financing enrollment in traditional college programs toward obtaining an approved degree and many accredited certificate programs.

• Employee Stock Purchase Plan allowing shares to be purchased at 85% of the lower of two prices (Beginning or End of the purchase period).