Health Claims Specialist

Job Summary

To support the accurate and timely processing of stop loss claims, the full-time Health Claims Stop Loss Specialist will manage claim submissions, maintain claimant files, and track reimbursements while ensuring effective communication between pharmacy benefit managers and internal teams.

Key responsibilities

• Prepare and file stop loss claim submissions, assessing eligibility and gathering necessary documentation
• Build and maintain accurate and complete claimant files throughout the claim lifecycle
• Track outstanding reimbursements and coordinate communication with stop loss carriers to resolve issues

Required qualifications

• High school diploma or GED required; additional education in healthcare or business is a plus
• Minimum 3 years of experience in stop loss, claims, or healthcare operations
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
• Proficient in Microsoft Office, including Word, Excel, and Outlook
• Experience with claims databases or reimbursement tracking systems