Stop Loss Claims Specialist

Allied is excited to announce that we are looking for a Stop Loss Claims Specialist to join our team! This person will be responsible for identifying, tracking, reviewing, and processing stop-loss reimbursements claims on behalf of carriers within an MGU stop-loss operation. An ideal candidate brings strong knowledge of medical claims, stop-loss policy interpretation, and large-claim management in a self-funded or TPA environment.

Duties/Responsibilities

· Review and process specific and aggregate stop-loss claims in accordance with policy provisions, carrier guidelines, and internal procedures

· Interpret stop-loss contracts and supporting plan documents to determine reimbursement eligibility, required documentation, and claim disposition

· Monitor high-cost and ongoing claims for reimbursement potential and follow up on outstanding submissions or requests for additional information

· Prepare, track, and report specific and aggregate claim activity, including aggregate accommodation calculations, monthly reporting, and audit support

· Analyze claims, medical documentation, and supplemental materials to ensure timely, accurate claim handling and clear audit trails

• Must have a high school diploma or equivalent. Associate or Bachelors in a related field is a plus.
• Needs to have 3+ years of experience in medical claims processing, stop-loss administration, aggregate claim review and processing, large claim review, or a related self-funded environment
• Must be able to read, interpret, and apply stop-loss contracts, policy language, and supporting plan documents

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