Medical Stop Loss Claims – Group Insurance

Job Description:

• Develop and execute the vision, strategy, and operating model for Prudential's Stop Loss Claims function
• Establish scalable workflows, governance, and best practices that support continued growth and operational excellence
• Partner in the design, implementation, and optimization of claims technology solutions
• Provide subject matter expertise to ensure efficient workflows and industry-leading claims practices
• Recruit, develop, and lead a high-performing claims organization
• Foster a culture of accountability, collaboration, continuous improvement, and professional development
• Review and approve high-dollar and complex medical stop loss claims
• Ensure consistent, accurate claim adjudication aligned with policy provisions, contractual obligations, and company standards
• Serve as the primary claims leader and ambassador for Prudential's Medical Stop Loss business
• Build strong relationships with brokers, TPAs, reinsurers, vendors, consultants, and internal partners
• Leverage data, analytics, and technology to improve accuracy, efficiency, and service delivery
• Drive process improvements that reduce cycle times and enhance the customer experience
• Ensure adherence to all applicable federal and state regulations, contractual requirements, and internal controls
• Collaborate across underwriting, implementation, account management, finance, actuarial, and operations teams to deliver seamless end-to-end service

Requirements:

• 10+ years of experience in group insurance claims including some meaningful experience supporting medical stop loss claims operations
• Deep knowledge of stop loss claim adjudication, reimbursement methodologies, policy interpretation, and industry best practices
• Proven experience leading teams and driving operational transformation in a growing organization
• Strong understanding of medical terminology, CPT/HCPCS/ICD-10 coding, stop loss policy language, and claims workflows
• Proficiency with Microsoft Office applications, including Excel, Word, PowerPoint, and Outlook
• Bachelor's degree in Business, Healthcare Administration, or a related field preferred.

Benefits:

• Medical, dental, vision, life insurance, disability insurance
• Paid Time Off (PTO)
• Leave of absences, such as parental and military leave
• 401(k) plan with company match (up to 4%)
• Company-funded pension plan
• Wellness Programs including up to $1,600 a year for reimbursement of items purchased to support personal wellbeing needs
• Work/Life Resources to help support topics such as parenting, housing, senior care, finances, pets, legal matters, education, emotional and mental health, and career development
• Education Benefit to help finance traditional college enrollment toward obtaining an approved degree and many accredited certificate programs
• Employee Stock Purchase Plan: Shares can be purchased at 85% of the lower of two prices (Beginning or End of the purchase period)