Stop Loss Coordinator Job at Daley and Associates (Chicago)

Stop Loss Coordinator

We are looking for a highly organized and detail-oriented Stop Loss Coordinator ...

Location

United States , Feasterville-Trevose

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Minimum of 2 years of experience in stop loss claims processing or a related field
Proficiency in handling insurance reimbursement and account reconciliation
Strong knowledge of stop loss policies and claims procedures
Exceptional organizational skills to maintain accurate and detailed documentation
Ability to analyze data and address carrier requests or denials effectively
Excellent communication skills for coordinating with internal teams and external carriers
Familiarity with industry-specific regulations and compliance standards
Capability to work independently and manage multiple tasks efficiently

Job Responsibility

Manage the complete lifecycle of stop loss claims, from submission to resolution, ensuring timely and accurate processing
Coordinate with the Finance department to reconcile reimbursements and payments effectively
Monitor pending claims submissions and promptly respond to carrier requests for additional information
Review and interpret stop loss policies to confirm compliance with reimbursement and claims requirements
Maintain thorough and organized records of claims documentation and correspondence following company procedures
Analyze claims data and address carrier denials or requests for further clarification
Provide regular updates to management regarding claim statuses, pending issues, and expected resolution timelines
Collaborate with internal teams to gather necessary information for claims processing
Perform additional duties as assigned to support the overall claims management process

What we offer

medical
vision
dental
life and disability insurance
401(k) plan

Stop Loss Auditor

A Connecticut based Medical Insurance company is seeking an experienced Stop Los...

Location

United States

Salary:

65000.00 - 75000.00 USD / Year

Daley and Associates

Expiration Date

Until further notice

Requirements

3+ years of medical stop loss insurance experience (required)
Experience auditing stop loss or first-dollar medical claims
Strong knowledge of: Plan Documents and Stop Loss policies, Reinsurance contracts, Medical terminology and coding (ICD-10, HCPCS, CPT-4)
Ability to work independently in a remote environment while collaborating with a team

Job Responsibility

Audit medical stop loss claims for assigned clients
Review and approve Plan Documents to ensure compliance
Evaluate reimbursement requests and determine claim validity
Verify claims are paid according to Plan Documents and Stop Loss policies
Confirm participant and dependent eligibility
Review high-cost claims for financial accuracy, coding accuracy, and cost containment coordination
Process claim reimbursements on behalf of carriers/reinsurers
Maintain accurate and detailed claim documentation
Meet established accuracy and turnaround time standards
Identify and recover overpaid claims through refund requests

Fulltime

Senior Stop Loss Auditor

A Connecticut based Medical Insurance company is seeking an experienced Senior S...

Location

United States

Salary:

75000.00 - 90000.00 USD / Year

Daley and Associates

Expiration Date

Until further notice

Requirements

3+ years of medical stop loss insurance experience at the Senior level (required)
Experience auditing stop loss or first-dollar medical claims
Strong knowledge of: Plan Documents and Stop Loss policies, Reinsurance contracts, Medical terminology and coding (ICD-10, HCPCS, CPT-4)
Ability to work independently in a remote environment while collaborating with a team

Job Responsibility

Lead audits of complex and high-cost medical stop loss claims for assigned clients
Interpret and apply Plan Documents and Stop Loss policy provisions
Evaluate reimbursement submissions and render claim determinations
Verify eligibility, financial accuracy, and medical coding compliance
Review claims for coordination with cost containment programs
Ensure claims are processed within established accuracy and turnaround standards
Identify and pursue recovery of overpaid claims
Maintain detailed audit documentation and reporting
Partner with TPAs, carriers, and internal teams throughout the approval process
Support cross-functional collaboration and knowledge sharing across teams

Fulltime

Stop Loss Specialist

We're seeking a detail-oriented professional who can support the coordination an...

Location

United States , Covington

Salary:

21.00 - 23.00 USD / Hour

Personify Health

Expiration Date

Until further notice

Requirements

High school diploma or general education degree (GED) required
Minimum 3 years related experience and/or training, or equivalent combination of education and experience
Completion of training programs through HIPAA, ICA and/or LOMA, and continuing education courses relative to Stop Loss preferred
Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
Computer literacy with proficiency in Windows and Microsoft Office environment (Word, Excel, Outlook)
Knowledge of insurance database systems preferred
Experience with EDOCS platform or similar documentation management systems
Detail-oriented, analytical, financially minded approach to Stop Loss coordination
Ability to read, analyze, and interpret common financial reports and legal documents
Capability to work with mathematical concepts such as probability and statistical inference

Job Responsibility

Prepare Stop Loss submissions: Analyze Stop Loss claims and applicable documents to determine filing eligibility under Excess Loss Policy while processing all submissions within established timeframes
Coordinate funding requests: Manage Advanced Funding Requests with clients and Stop Loss carriers while maintaining comprehensive database of all specific reimbursement requests
Manage documentation systems: Create initial Specific File for each claimant and file all submissions in EDOCS platform while coordinating release of Over Specific, System Hold claims
Serve as liaison: Act as connection point between PBMs and internal clients for Stop Loss claimants while maintaining professional communication with all stakeholders
Monitor reimbursements: Track all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reimbursement reports and following up with carriers
Support plan year activities: Assist with Plan Year End Closeouts while keeping immediate supervisor apprised of open or disputed items requiring attention
Maintain workflow excellence: Contribute to daily workflow with regular, punctual attendance while performing related or assigned duties as required

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions
Paid Time Off
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact on people's health

Fulltime

Health Claims Stop Loss Specialist

We're seeking a detail-oriented professional who can support the coordination an...

Location

United States

Salary:

19.00 - 22.00 USD / Hour

Personify Health

Expiration Date

Until further notice

Requirements

High school diploma or general education degree (GED) required
Minimum 3 years related experience and/or training, or equivalent combination of education and experience
Completion of training programs through HIPAA, ICA and/or LOMA, and continuing education courses relative to Stop Loss preferred
Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
Computer literacy with proficiency in Windows and Microsoft Office environment (Word, Excel, Outlook)
Knowledge of insurance database systems preferred
Experience with EDOCS platform or similar documentation management systems
Detail-oriented, analytical, financially minded approach to Stop Loss coordination
Ability to read, analyze, and interpret common financial reports and legal documents
Capability to work with mathematical concepts such as probability and statistical inference

Job Responsibility

Prepare Stop Loss submissions: Analyze Stop Loss claims and applicable documents to determine filing eligibility under Excess Loss Policy while processing all submissions within established timeframes
Coordinate funding requests: Manage Advanced Funding Requests with clients and Stop Loss carriers while maintaining comprehensive database of all specific reimbursement requests
Manage documentation systems: Create initial Specific File for each claimant and file all submissions in EDOCS platform while coordinating release of Over Specific, System Hold claims
Serve as liaison: Act as connection point between PBMs and internal clients for Stop Loss claimants while maintaining professional communication with all stakeholders
Monitor reimbursements: Track all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reimbursement reports and following up with carriers
Support plan year activities: Assist with Plan Year End Closeouts while keeping immediate supervisor apprised of open or disputed items requiring attention
Maintain workflow excellence: Contribute to daily workflow with regular, punctual attendance while performing related or assigned duties as required

What we offer

Comprehensive medical and dental coverage through our own health solutions
Mental health support and wellness programs designed by experts who get it
Flexible work arrangements that fit your life
Retirement planning support to help you build real wealth for the future
Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage
Professional development opportunities and clear career progression paths
Mentorship from industry leaders who want to see you succeed
Learning budget to invest in skills that matter to your future
Competitive base salary that rewards your success

Fulltime

Senior Account Support Analyst

This role provides critical sales account support for HM Insurance Groups' Stop ...

Location

United States , Houston

Salary:

Not provided

Highmark Health Options

Expiration Date

Until further notice

Requirements

High School Diploma/GED
5-10 years of relevant, progressive experience in the area of specialization

Job Responsibility

Load and maintain group information and benefit files
Interact and provide support activities to Account Managers
Resolve benefit inquiries received from Account Managers, producers, sales reps and small market clients
May coordinate meetings, projects, implementations with clients and core partners
Handle error management and ensure files are corrected
Analyze/coordinate the implementation of new products, group changes, benefit enhancements, non-standard benefits and activities related to mass updates
Act as a resource for colleagues with less experience
Other duties as assigned or requested

Fulltime

Clinical Specialist, Quality Management I

Who We Are: Because health is personal. That's why Personify Health created the ...

Location

United States

Salary:

60600.00 - 91000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Active, unrestricted Registered Nurse (RN) license required
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Ability to work independently and utilize written resources to problem solve
After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations
Level I: In-depth knowledge of applicable regulations and accreditation standards (HIPAA, CMS requirements as applicable, NCQA, URAC)

Job Responsibility

Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable)
Conduct internal and external audits of UM/CM/CDM processes and documentation
prepare audit files, findings, and corrective action recommendations
Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution
Review and support SOPs and workflows to ensure regulatory alignment and operational clarity
Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance
Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows
Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions
Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners
Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Unlimited PTO—rest and recharge time is non-negotiable
Mental health support, retirement planning, and financial protection
Professional development with clear career progression and learning budgets
Mission-driven culture where diverse perspectives drive real impact on people's health

Fulltime

Director Regional Sales 1 - HMIG

A senior level professional sales representative, the incumbent is responsible f...

Location

United States , New York City

Salary:

88000.00 - 132000.00 USD / Year

Highmark Health Options

Expiration Date

Until further notice

Requirements

Bachelors in BA or High School diploma or GED with Six years experience in sales, marketing selling group products, such as Life/AD&D, STD, LTD, DBL, Stop Loss and Vision Insurance products, as well as understanding the concepts of risk, underwriting, actuarial, pricing, loss ratio, and regulations
Accident and Health Sales License
CLU or other industry recognized certifications such as HIAA, CEBS, CBP, etc. and/or extensive experience in group product sales
Possess a thorough knowledge of the insurance business with experience in Life, Health, and Accident and carry the required licenses to be able to sell these products
Above average leadership and motivational skills
Experience in managing a support staff
Good people skills, fact finding skills, as well as sales skills
Must have a valid driver's license and reliable transportation

Job Responsibility

This position is responsible for maintaining existing business, generating new business revenue, and growing a profitable book of business in the Group Insurance market
Work with management to develop strategies for complex and unusual sales opportunities, as well as on new techniques, products, services or policies to improve the overall profitability of the company and provide guidance to lower levels
Work through distribution channels of existing and new producers, joint venture partners including Blue Plans, and work with other partners in the promotion of a core product line: Employer Stop Loss and other lines as determined by management
Identify target producers, and then independently develop, manage, and make decisions about the producers and cases that should be worked on, based on potential to generate new business revenue and profitable business for the corporation
Develop and work with new and existing partners and producers within assigned territory and build relationships with them and their customers, identifying prospects, and promoting HM Insurance Group products and strategies, generating new sales activity that will lead to new business revenue, and retaining profitable clients upon renewal
Create and achieve a regional sales plan that will effectively meet the needs of the corporation in that region
Promote products and strategies, generating new sales activity that will lead to new business revenue, and retaining profitable clients upon renewal
Manage relationships with producers who will generate group prospects, and will manage the entire sales process that will lead to sold cases and generate new business revenue
For renewing groups, be responsible for retention and profitability
Build files, collect data, coordinate and manage information, build and enhance producer relationships, while promoting solutions to meet customer needs

Fulltime

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Stop Loss Coordinator

Job Description

Job Responsibility

Requirements

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