Medical Stop Loss Claims Group Insurance (Remote)

Job Classification:

Prudential is continuing to grow and expand its capabilities as a premier medical stop loss carrier. As part of this exciting evolution we are seeking a Head of Stop Loss Claims to build and lead our claims organization.

This is a unique opportunity for a hands-on leader who thrives in high-growth environments and is energized by creating processes developing talent and shaping the future of a business. Youll play a critical role in designing our claims operations driving innovation and ensuring an exceptional experience for our customers brokers consultants and partners.

Strategic Leadership

• Develop and execute the vision strategy and operating model for Prudentials Stop Loss Claims function.
• Establish scalable workflows governance and best practices that support continued growth and operational excellence.

Claims System Development

• Partner in the design implementation and optimization of claims technology solutions.
• Provide subject matter expertise to ensure efficient workflows and industry-leading claims practices.

Team Building & Leadership

• Recruit develop and lead a high-performing claims organization.
• Foster a culture of accountability collaboration continuous improvement and professional development.

Claims Oversight

• 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.

Stakeholder Management

• Serve as the primary claims leader and ambassador for Prudentials Medical Stop Loss business.
• Build strong relationships with brokers TPAs reinsurers vendors consultants and internal partners.

Operational Excellence & Innovation

• Leverage data analytics and technology to improve accuracy efficiency and service delivery.
• Drive process improvements that reduce cycle times and enhance the customer experience.

Regulatory Compliance

• Ensure adherence to all applicable federal and state regulations contractual requirements and internal controls.

Cross-Functional Partnership

• Collaborate across underwriting implementation account management finance actuarial and operations teams to deliver seamless end-to-end service.

Required Experience

• 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.

Technical Expertise

• 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.

Leadership Characteristics

• Builder mindset with the ability to create structure in a growing business.
• Strong executive presence communication skills and stakeholder management capabilities.
• Demonstrated success leading through change influencing across functions and developing talent.

Education

• Bachelors degree in Business Healthcare Administration or a related field preferred.

• Market competitive base salaries with a yearly bonus potential at every level.
• Medical dental vision life insurance disability insurance Paid Time Off (PTO) and 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 $1600 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).

Eligibility to participate in a discretionary annual incentive program is subject to the rules governing the program whereby an award if any depends on various factors including without limitation individual and organizational performance. To find out more about our Total Rewards package visit Work Life Balance Prudential Careers. Some of the above benefits may not apply to part-time employees scheduled to work less than 20 hours per week.

Prudential Financial Inc. of the United States is not affiliated with Prudential plc. which is headquartered in the United Kingdom.

Prudential is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race color religion national origin ancestry sex sexual orientation gender identity national origin genetics disability marital status age veteran status domestic partner status medical condition or any other characteristic protected by law.

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