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About SPG:
Specialty Program Group (SPG) is the wholesale & MGA division of HUB International (5th Largest Global Broker). SPG acts in a holding company capacity acquiring best in class underwriting businesses to operate independently under discrete brands (portfolio companies).
Strategic Benefit Resources provides complete facilitation of specific and aggregate stop loss claims. Our comprehensive approach begins with a thorough review of the claims submission and ends with an expedited and accurate reimbursement.
Position Summary
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…