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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates extensive expertise in managing complex claims, particularly in Medical Stop Loss, while applying legal precedents and claims accounting practices. Proven ability to develop action plans, mentor team members, and influence stakeholder decisions in a collaborative environment.
Highest-signal resume keywords
Complex Claims ManagementMedical Stop Loss ExpertiseClaims Accounting KnowledgeExcellent Communication SkillsCreative Problem-Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Complex Claims PracticesLegal PrecedentsClaims AccountingHealthcare LegislationAction Plan DevelopmentCase Management StrategiesClaims Reimbursement PracticesClaims Management TechniquesNegotiation SkillsConflict Resolution
Soft Skills
Strong JudgmentInitiativeConsultative Decision-MakingInfluencing SkillsMentoring
Industry Keywords
Claims PoliciesMedical ClaimsPeer PresentationsProfessional ForumsStakeholder AlignmentService QualityIndustry TrendsEmerging TechniquesDiverse CollaborationSettlement Discussions
About the role
Key responsibilities & impact- Manage overall claim risk, including pay/deny decisions, by applying contract language and developing action plans for complex Stop Loss claims
- Coordinate complex claims activity across multiple parties
- Identify and monitor evolving medical and prescription drug trends
- Apply responsive case management strategies
- Resolve unique or precedent-setting matters using complex claim practices and legal precedents
- Establish, refine, and institutionalize claims policies and best practices with peers and leadership
- Manage communications with policyholders, administrators, top-tier brokers, sales representatives, vendors, and internal partners
- Coach and mentor less experienced team members
- Develop learning modules and support technical development
- Train new hires on accurate claim reimbursement practices and client service expectations
- Manage monthly accommodation advance payment claims and assigned claim blocks while maintaining turnaround times and service quality
- Stay current on industry practices and contribute to evolving claims management techniques
- Serve as a departmental leader and subject matter expert
- Participate in field visits and settlement discussions
Requirements
What you’ll need- 7+ years of experience handling complex claims, Medical Stop Loss or complex Medical Claims
- Deep knowledge of complex claim practices, legal precedents, claims accounting, and applicable state and federal healthcare legislation
- Strong judgment, initiative, and consultative decision-making
- Ability to influence recommendations that may impact company operations
- Recognized subject matter expertise, including industry involvement through peer presentations, panels, or professional forums
- Established industry network to exchange ideas, trends, and emerging claim management techniques
- Excellent communication, negotiation, and influencing skills
- Ability to navigate conflict and align stakeholders
- Ability to draft clear, compliant written correspondence
- Creative, resourceful problem-solving skills
- Ability to develop action plans and resolve complex matters using specialized resources or claims management techniques
- Ability to work with a diverse range of people
Benefits
Comp & perks- Generous vacation and sick time
- Market-leading paid family, parental and adoption leave
- Medical coverage
- Company-paid life and AD&D insurance
- Disability programs
- Partially paid sabbatical program
- 401(k) employer match
- Stock purchase options
- Employer-funded retirement account
- Flexible, inclusive and collaborative work environment
- Career growth support
- Discretionary annual incentive award based on individual performance and overall business performance