Clinical Operations Specialist, Medical Stop Loss – Remote Full Time

1. About Our Client:

The organization operates in the specialty and standard commercial lines insurance sector, offering both admitted and surplus lines products. With a history dating back to 1822, it holds a financial strength rating of “A+” (Superior) by AM Best. The company focuses on providing risk management services through claims and risk engineering, with a workforce of over 2000 employees across the United States. Recognized for its employee-first approach and commitment to diversity, equity, and inclusion, it has received multiple workplace and wellness awards. As part of a global financial holdings group, the organization’s Accident & Health division delivers specialty insurance and reinsurance products nationwide, with a strong emphasis on product development, creative distribution, and client service. The division supports both domestic and international markets through partnerships and a diversified business model, including program partnerships and direct sales in Employer Stop Loss, with over $1 billion in gross premiums recorded at the end of 2025.

2. About the Opportunity:

The **Clinical Operations Specialist** in the Medical Stop Loss unit plays a key role in supporting the Employer Stop Loss segment of the Medical Business Unit. This position is vital for managing claims data and clinical information throughout underwriting and cost containment processes. The role contributes to efficient team operations, project support, and maintaining high standards in risk management services. It ensures smooth communication across clinical, underwriting, and cost containment teams, helping the organization maintain its leadership in this insurance niche.

3. Responsibilities:

• Receive, track, and analyze claims data and clinical information for pre-renewal, underwriting, and cost containment

• Set up referral and review documents accurately using various medical underwriting and cost containment platforms

• Comply with company policies, procedures, and service level agreements

• Generate system-based reports for management to monitor department performance

• Maintain a positive work ethic and collaborate effectively with team members

• Assign notices and referrals to appropriate parties systematically

• Refer claimants for reserves and cost containment according to guidelines, escalating complex issues as needed

• Use data manipulation tools like Excel, PDF, and Word to prepare referral files for clinical review

• Participate in IT system updates relevant to stop loss programs

• Create reports based on business needs

• Communicate effectively with team and management on activities and issues

• Deliver timely and appropriate customer service to internal and external clients

• Complete additional special projects as assigned

4. Requirements:

• Bachelor’s degree from an accredited college or university

• Preferred experience in Employer Stop Loss claims or notification

• Advanced proficiency with Excel, Word, Outlook, SharePoint, OneDrive, and other PC applications

• Preferred knowledge of medical terminology and claim coding

• Strong customer service skills and commitment to customer satisfaction

• Ability to prioritize workload effectively, especially during high-volume periods

• Attention to detail and accuracy in task completion

• Persistent dedication to quality work despite challenges

• Accountability and pride in responsibilities

• Ability to work independently and collaboratively

• Strong organizational, critical thinking, and time management skills

• Effective verbal and written communication skills

• Ability to interpret complex information with moderate supervision

• Quick learning ability and willingness to acquire new skills

5. Pay Range and Compensation Package:

• The pay range and compensation package for this role will be determined based on the candidate’s experience, skills, and other relevant factors.

6. Benefits & Perks:

• Competitive compensation package

• Generous 401K employer match

• Employee Stock Purchase plan with employer matching

• Generous Paid Time Off

• Comprehensive health, dental, and vision benefits focusing on physical, mental, and financial wellness

Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin.

Note:

RemoteHunter is not the Employer of Record (EOR) for this role. Our purpose in this opportunity is to connect exceptional candidates with leading employers. We help job seekers worldwide discover roles that match their goals and guide them to complete their full application directly through the hiring company’s career page or ATS.