Medical Stop Loss Claims – Group Insurance

🕒 July 2

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $106k - $174.9k / year

⏰ Full Time

🟠 Senior

🔴 Lead

🔒 Insurance

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Prudential Financial

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1875

💸 Finance

🛡️ Insurance

🏠 Real Estate

Finance • Insurance • Real Estate

Prudential Financial is a multinational financial services leader with operations in the United States, Asia, Europe, and Latin America. With a heritage in life insurance and asset management, the company helps individual and institutional customers grow and protect their wealth. Prudential offers a variety of products and services, including life insurance, annuities, retirement-related services, mutual funds, asset management, and real estate services.

📋 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)