Stop Loss Claims Manager

Stop-Loss Claims Manager

The Stop-Loss Claims Manager oversees the administration, adjudication, and resolution of stop-loss insurance claims, ensuring accuracy, compliance, and timely processing. This role serves as a critical liaison between employers, third-party administrators (TPAs), brokers, and carriers, managing high-cost claims that exceed predetermined thresholds.

The successful candidate combines deep technical claims knowledge with strong communication and analytical skills to protect organizational interests while maintaining strong relationships across all stakeholders.

Key Responsibilities

• Claims Administration & Adjudication: Review, evaluate, and adjudicate specific and aggregate stop-loss claims in accordance with policy provisions, contractual terms, and regulatory requirements.
• Documentation & Verification: Analyze claim submissions, medical records, and supporting documentation to validate eligibility, accuracy, and reimbursement amounts.
• Stakeholder Liaison: Serve as the primary point of contact between employers, TPAs, brokers, and carriers to facilitate clear communication and expedite claim resolution.
• High-Cost Claim Management: Monitor claims approaching or exceeding specific deductible thresholds; proactively flag, track, and manage catastrophic and trigger-diagnosis cases.
• Compliance Oversight: Ensure all claims handling adheres to applicable federal and state regulations (ERISA, HIPAA, ACA) and internal policies.
• Reporting & Analytics: Prepare and present claims reports, loss runs, and trend analyses for internal leadership and external partners; identify cost-driver patterns and recommend mitigation strategies.
• Process Improvement: Identify opportunities to streamline workflows, reduce turnaround times, and enhance claim handling quality.
• Dispute Resolution: Investigate and resolve disputed, denied, or contested claims, coordinating with legal and clinical resources when escalation is required.
• Vendor Management: Oversee relationships with reinsurers, case managers, and cost-containment vendors to ensure performance, accuracy, and contract compliance.
• Team Leadership: Mentor, train, and provide technical guidance to claims analysts and support staff; may directly supervise junior team members.

Required Qualifications

• Bachelor's degree in Business, Insurance, Risk Management, Healthcare Administration, or a related field (equivalent experience considered).
• 5+ years of progressive experience in stop-loss, medical, or health insurance claims, with at least 2 years in a senior or supervisory capacity.
• Comprehensive knowledge of self-funded health plans, stop-loss contracts (specific and aggregate), and claims adjudication processes.
• Strong understanding of medical terminology, ICD/CPT coding, and Usual & Customary (U&C) reimbursement methodologies.
• Working knowledge of ERISA, HIPAA, ACA, and other relevant healthcare and insurance regulations.
• Proficiency in claims management systems and Microsoft Office Suite (advanced Excel preferred).
• Excellent analytical, organizational, and decision-making skills with a high attention to detail.
• Strong written and verbal communication skills, with the ability to negotiate and influence across multiple stakeholders.

Preferred Qualifications

• Industry designations such as AIC, CPCU, HIAA, or SIE.
• Prior experience working directly with TPAs, MGUs, or reinsurance carriers.
• Clinical background or experience collaborating with nurse case managers on complex claims.
• Experience with data visualization or claims analytics platforms (e.g., Tableau, Power BI).

Key Competencies

• Sound judgment in evaluating complex, high-dollar claims.
• Diplomatic communication and relationship management across diverse stakeholder groups.
• Ability to manage multiple priorities under tight deadlines.
• Commitment to accuracy, integrity, and confidentiality.

Work Environment & Physical Requirements

Standard office or remote work environment. Extended periods of computer use required. Occasional travel may be necessary to meet with clients, carriers, or attend industry conferences.

Salary Transparency:

The expected salary range for this position is $50,000 - $55,000 annually and will be impacted by factors such as the successful candidate's skills, experience and working location, as well as the specific position's business line, scope and level. HUB International is proud to offer comprehensive benefit and total compensation packages which could include health/dental/vision/life/disability insurance, FSA, HAS and 401(k) accounts, paid-time-off benefits such as vacation, sick, personal, floating holidays and company holidays. In addition, eligible annual bonuses, equity and commissions may be available for some positions.

What we offer you

We invest in your growth. HUB offers structured training, licensing support and ongoing development opportunities designed to accelerate your career.

• Competitive pay with comprehensive health benefits, retirement savings matching and company-paid life and disability plans
• Generous paid time off, paid parental leave and a wellbeing program designed to support real work/life balance
• A collaborative, high-performing culture with meaningful engagement, community impact through HUB Gives and genuine room to grow your career
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The HUB difference

HUB International is one of North America's largest insurance brokers, delivering risk management, insurance, employee benefits, retirement and wealth management solutions to businesses and individuals across the United States and Canada through locally led teams backed by national expertise, giving you the agility of a local partner and the reach of a global organization.

Equal Employment Opportunity: HUB International Limited 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, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.

Reasonable Accommodations: HUB International Limited is committed to providing reasonable accommodations to qualified individuals with disabilities throughout the application and hiring process. If you need a reasonable accommodation to access our career site, complete an application, or participate in any part of the hiring process, please contact the Recruiting Team at View email address on click.appcast.io. This contact information is for accommodation requests only and should not be used to inquire about the status of an application.

E-Verify: HUB International Limited participates in E-Verify. Please refer to Our Recruiting Process | Applicant Notices: E-Verify Program for additional information.