Stop Loss Specialist

Who are we? Yuzu is a tech-enabled, vertically integrated Third Party Administrator (TPA) that powers innovative health plans centered on care navigation, capitated primary care, and real-time payments. Unlike traditional TPAs, we partner closely with plan designers who serve as care navigators, contract negotiators, and sales teams for the uniquely tailored plans they create. We currently support thousands of employees and differentiate ourselves by helping new models of healthcare delivery come to life — enabling new ways to access and pay for care through health care coverage. Our goal is simple: make it easy for any business to build and manage a custom health plan. We do this by efficiently processing claims, ensuring regulatory compliance, and building technology that enables custom payment flows and seamless collaboration across stakeholders. Equally important, we provide our members with high-quality support to ensure they have the guidance and assistance they need at every step of their healthcare journey. As we continue to grow, we’re excited to welcome another talented member of the Claims team to help us maintain our standard of exceptional service and innovation. The Role: The Stop Loss Specialist is responsible for coordinating all activities related to stop loss insurance for self-funded employer groups. This role ensures accurate and timely submission of stop loss claims, manages ongoing claimant reporting, and serves as the primary liaison between the TPA, stop loss carriers, brokers, and internal departments. The Stop Loss Specialist plays a critical role in mitigating financial risk by monitoring high-cost claimants, validating plan liability, and ensuring compliance with policy provisions and contractual requirements. Key Responsibilities: Stop Loss Claims Management Prepare, compile, and submit initial and ongoing stop loss claims in accordance with carrier-specific requirements. Review claims data to validate eligibility, plan benefits, accumulators, provider billing accuracy, and patient responsibility prior to submission. Track reimbursements and reconcile payments against expected recoveries. Maintain timely follow-up with stop loss carriers to resolve outstanding items or additional documentation requests. High-Cost Claimant Oversight Identify potential stop loss claimants through daily/weekly high-dollar reporting. Monitor claims approaching the specific deductible and ensure accurate accumulation. Maintain updated logs for submission tracking purposes. Policy & Contract Administration Review stop loss policies to ensure adherence to contract terms, exclusions, and filing deadlines. Coordination & Communication Serve as the primary contact for stop loss carriers and employer groups regarding claim statuses and policy questions. Collaborate closely with Claims team members to gather needed documentation. Data Integrity & Reporting Maintain accurate and secure records of all stop loss claims and reimbursement records. Ensure all documentation meets audit and compliance standards. Who We’re Looking For: We’re seeking a motivated, ethical, and compassionate individual who thrives in a fast-paced, detail-oriented environment and is passionate about delivering fair and accurate outcomes. If you’re passionate about doing the right thing and bringing integrity to every claim, we’d love to hear from you. Ideal Candidates Would Possess: Experience in healthcare claims processing, preferably within a mid-sized TPA operating in the self-funded space A strong commitment to accuracy and attention to detail The ability to prioritize workload effectively in a fast-paced environment Strong communication skills What Will Make You Stand Out: Experience in stop loss administration, medical claims processing, or self-funded health plan operations (typically 2–5 years). Strong understanding of medical claims, ICD-10, CPT, billing rules, and plan document interpretation. Knowledge of stop loss concepts (specific/aggregate deductibles, lasers, reimbursement timelines). Proficiency in claims platforms, Excel, and reporting tools. Excellent analytical and problem-solving skills. Strong communication and time-management abilities. Why Join Us: Equity opportunities Competitive Salary Approximately $80 - $90k in annual salary depending on experience, location, and desired equity Health benefits 401K with Employer matching Career growth and development opportunities Remote capabilities We are a high-trust team with radically high transparency and autonomy Our Interview Process: If you’re selected for an interview, here’s what you can expect: Initial 30–45 minute video conversation with Claims Operations Leadership Follow-up conversation with members of the broader Operations Leadership team Take-home assignment (approx. 2 hours) designed to reflect real on-the-job work Reference checks with 1–2 individuals you provide Possible onsite visit to our NYC office, depending on your location and role expectations #J-18808-Ljbffr Yuzu Health