Risk & Reimbursement Specialist — Stop-Loss Claims

Edison Health Solutions, LLC; Tulsa (OK); On-site; USD 29,000 - 50,000; Full time

Job summary

Relation Insurance Services seeks a Risk Management Specialist to oversee the end-to-end administration of stop-loss claims for self-funded plans. You will collaborate with carriers, claims teams, and account executives to maximize recoveries and ensure timely reimbursements while maintaining strict adherence to policy language and deadlines.

The role emphasizes data collection, documentation, and reconciliation, using AI tools to enhance interpretation of coverage terms and ensure compliance

Qualifications

• High school diploma or equivalent required.
• Four-year degree preferred.
• Minimum 1 year of experience in health insurance, claims administration or operations, or a reimbursement-related field.
• Prior experience with stop-loss insurance preferred.
• Familiarity with insurance carriers and reimbursement processes preferred.
• Strong attention to detail and ability to follow written procedures in a compliance-sensitive environment.
• Ability to interpret basic policy language and follow processes accurately.
• Intermediate computer proficiency, specifically with Microsoft products and the ability to learn new systems.
• Excellent written and verbal communications skills are required to maintain effective relationships with clients, co-workers, carriers, vendors and others.

Responsibilities

• Manages the stop-loss claims lifecycle, from initial submission through final reimbursement and closure.
• Coordinates directly with stop-loss carriers to facilitate claim review, respond to requests for additional information, resolve discrepancies, and ensure timely and accurate reimbursement payments.
• Partners with internal teams, including claims and account executives, to gather claim data, resolve issues, and move claims through the reimbursement process efficiently and effectively.
• Collects, reviews and manages required documentation from brokers, employer group, members and internal stakeholders, ensuring submissions are complete, compliant and submitted within contractual deadlines.
• Reviews and validates paid claims reports, reimbursement calculations, and reconciliation data to maximize eligible recoveries and ensure employers receive all funds due under stop-loss policy provisions.
• Maintains organized records with detailed and accurate documentation.
• Analyzes and interprets stop-loss policy language and insurance contracts, including coverage provisions, exclusions, deductibles, and reporting requirements to determine claims eligibility and reimbursement accuracy.
• Ensures ongoing compliance with stop-loss policy requirements, documentation standards, and submission deadlines, proactively identifying risks, escalations, or process gaps that could delay or reduce reimbursement.
• Leverages proprietary AI tools to analyze stop-loss policy language and contract provisions, supporting quicker interpretation of coverage terms, exclusions, deductibles, and reporting requirements.
• Fully adopts innovative technology, including proprietary AI solutions, into the service process to deliver a best-in-class client service experience.
• Performs other projects, duties, and tasks, as assigned.

Skills

Attention to detail

Communication skills

Microsoft Office

Time management

Policy interpretation

Education

High school diploma or equivalent

Four-year degree preferred

Tools

Microsoft Excel

Job description

Relation Insurance Services seeks a Risk Management Specialist to oversee the end-to-end administration of stop-loss claims for self-funded plans. You will collaborate with carriers, claims teams, and account executives to maximize recoveries and ensure timely reimbursements while maintaining strict adherence to policy language and deadlines.

The role emphasizes data collection, documentation, and reconciliation, using AI tools to enhance interpretation of coverage terms and ensure compliance