Medical Stop Loss Claims – Group Insurance

Prudential Financial

Head of Stop Loss Claims leading Prudential's claims operations and ensuring exceptional customer experience. Shaping the future of medical stop loss claims through strategic leadership and team building.

Posted 7/2/2026full-timeRemote • New Jersey • 🇺🇸 United StatesSeniorLead💰 $106,000 - $174,900 per yearWebsite

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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)

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Stop Loss Claim AdjudicationReimbursement MethodologiesPolicy InterpretationCPT CodingHCPCS CodingICD-10 CodingClaims WorkflowsMicrosoft ExcelMicrosoft WordMicrosoft PowerPoint

Soft Skills

Team LeadershipCollaborationContinuous ImprovementAccountabilityProfessional Development