Stop Loss Claims Specialist
Imagine360 is seeking a Stop Loss Claims Specialist to join the team! This position coordinates the tracking, monitoring, documenting and submission of stop loss claims. This position maintains a comprehensive understanding of the plan document(s) under their scope of responsibility.
Position Location: 100% remote
Responsibilities include but are not limited to:
- Stop Loss Claims Management
- Compiles and submits stop loss claims to the carrier for reimbursement.
- Enters appropriate stop loss claims into designated database.
- Identifies, researches, and resolves stop loss carrier questions.
- Facilitates advancement funding with Finance Department.
- Ensures accurate, complete, and timely reporting and documentation in alignment with internal standards, regulatory requirements, and stop‑loss carrier expectations
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- Manages large case notifications process.
- Customer Service
- Acts as a role model in demonstrating the core values in customer service delivery.
- Provides timely and thorough follow up with internal and external customers.
- Appropriately escalates difficult issues up the chain of command.
- Quality Assurance
- Recognizes, documents, and alerts appropriate supervisor of trends.
- Performs self-quality monitoring to develop and execute plans to meet established goals.
- Collaborates with peers and cross-departmentally to improve or streamline procedures.
- Develops new or improves current internal processes to improve quality.
- Maintain detailed internal records of filing dates, amounts, expected reimbursements, and carrier determinations.
- Produce regular reports on open filings, reimbursements received, and aging items.
- Assist leadership with audits, carrier reviews, and process improvement initiatives.
Required Education/Experience:
- High School Diploma or GED
- 2-3 years of experience in medical claims administration, stop‑loss filings, or health insurance operations
- Experience working with self‑funded medical plans and understanding of stop‑loss concepts (specific and aggregate)
- Experience reviewing or preparing supporting documents such as:
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- EOBs
- Claims extracts
- Proof of payment
- Eligibility files
- Case management notes
Preferred Education/Experience:
- Associate degree in Business Administration, Healthcare Administration, Finance, or a related field.
- 3-5 years of experience in stop‑loss filings or high‑dollar medical claims.
- Prior experience working with stop‑loss carriers, TPAs, or reinsurance partners.
- Background in data verification, claim reconciliation, or financial review
Skills and Abilities:
- Working knowledge of computers and software including but not limited to Microsoft Office products
- Proficient mathematical, 10-key and typing skills
- Demonstrated organizational skills, problem-solving, analytical skills and detail oriented
- Demonstrated ability to remain neutral and maintain confidentiality
- Strong written and oral communication skills
- Demonstrated ability to work independently, prioritize workloads multi-task and manage priorities in order to meet deadlines
Licenses or Certification:
- None
Physical Requirements:
- Not specified
Imagine360 will make reasonable accommodations to enable applicants to participate in the interview process and other aspects of the hiring process, as well as for current employees, when Human Resources is aware of the need for such accommodations.
I understand that it is my responsibility to contact Human Resources if I need the company to consider making any accommodations to enable me to participate in the hiring process, including the interview, or for any of the job activities, duties or responsibilities included in this Job Description for any of the following reasons:
- Physical or mental health condition;
- Pregnancy or childbirth or medical conditions relating to the same; or
- Religious belief, practice or observance.
What can Imagine360 offer you?
- Multiple Health plan options
- Company paid employee premiums for disability and 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
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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we've helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today's one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.
Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.
**RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**