Stop Loss Claims Specialist

Allied National; Overland Park (KS); On-site; USD 65,000 - 90,000; Full time

Job summary

Allied-National is seeking a Stop Loss Claims Specialist to join our team in Overland Park, KS. You will identify, track, review, and process stop-loss reimbursements for carriers within a managed stop-loss operation.

The ideal candidate has 3+ years in medical claims processing, a strong understanding of stop-loss contracts, and experience in self-funded or TPA environments. Join a collaborative team focused on accurate, timely claim handling.

Qualifications

• Must have a high school diploma or equivalent.
• 3+ years of experience in medical claims processing, stop-loss administration, aggregate claim review, or related self-funded environment.
• Ability to read, interpret, and apply stop-loss contracts and plan documents.

Responsibilities

• Review and process stop-loss claims in accordance with policy provisions and procedures.
• Interpret stop-loss contracts and plan documents to determine reimbursement eligibility and claim disposition.
• Monitor high-cost and ongoing claims and follow up on required information.
• Prepare and report claim activity, including aggregate calculations and monthly reports.
• Analyze claims and medical documentation to ensure timely, accurate handling and audit trails.

Skills

Medical claims processing

Stop-loss administration

Aggregate claim review

Large claim review

Self-funded environment

Education

High school diploma or equivalent

Associate or Bachelor's degree in related field

Job description

Description

Allied is excited to announce that we are looking for a Stop Loss Claims Specialist to join our team! This person will be responsible for identifying, tracking, reviewing, and processing stop-loss reimbursements claims on behalf of carriers within an MGU stop-loss operation. An ideal candidate brings strong knowledge of medical claims, stop-loss policy interpretation, and large-claim management in a self-funded or TPA environment.

Duties/Responsibilities

• Review and process specific and aggregate stop-loss claims in accordance with policy provisions, carrier guidelines, and internal procedures
• Interpret stop-loss contracts and supporting plan documents to determine reimbursement eligibility, required documentation, and claim disposition
• Monitor high-cost and ongoing claims for reimbursement potential and follow up on outstanding submissions or requests for additional information
• Prepare, track, and report specific and aggregate claim activity, including aggregate accommodation calculations, monthly reporting, and audit support
• Analyze claims, medical documentation, and supplemental materials to ensure timely, accurate claim handling and clear audit trails

Requirements

• Must have a high school diploma or equivalent. Associate or Bachelors in a related field is a plus.
• Needs to have 3+ years of experience in medical claims processing, stop-loss administration, aggregate claim review and processing, large claim review, or a related self-funded environment
• Must be able to read, interpret, and apply stop-loss contracts, policy language, and supporting plan documents