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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 lead teams, develop training modules, and maintain high service quality in claims management.
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
Claims Risk ManagementCase Management StrategiesClaims Policy DevelopmentLegal Precedent ApplicationClaims Reimbursement Practices
Soft Skills
Strong JudgmentConsultative Decision-MakingNegotiation SkillsConflict NavigationTeam Mentoring
Industry Keywords
Healthcare LegislationClaims Management TechniquesStakeholder AlignmentPeer PresentationsEmerging Trends
About the role
Key responsibilities & impact- Manage overall claim risk, including pay/deny decisions, for complex Stop Loss claims
- Coordinate complex claims activity across multiple parties
- Identify and monitor medical and prescription drug trends
- Apply case management strategies to evolving claims matters
- Resolve unique or precedent-setting matters using complex claim practices and legal precedents
- Establish, refine, and institutionalize claims policies and best practices
- Manage communications with policyholders, administrators, 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 claim reimbursement practices and client service expectations
- Manage monthly accommodation advance payment claims and assigned claim blocks
- Maintain turnaround times and service quality
- 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
- 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 work with a diverse range of people
- Ability to work in the contiguous states plus Alaska
Benefits
Comp & perks- Generous vacation and sick time
- 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