Job Description

Company Details

Berkley Accident and Health is a risk management company that designs innovative solutions to address the unique challenges of each client. With our entrepreneurial culture and a strong emphasis on analytics, we can help employers better manage their risk. We offer a broad range of products, including employer stop loss, benefit captives, provider stop loss, HMO reinsurance, and specialty accident. The key to Berkley’s success is our nimble approach to risk – our ability to quickly understand, think through, and devise a plan that addresses each client’s challenges, coupled with the strong backing of a Fortune 500 company. Our parent company, W. R. Berkley Corporation, is one of the largest and best managed property/casualty insurers in the United States.

#LI-AV1 #LI-REMOTE

The Company is an equal employment opportunity employer.

Responsibilities

Shape High-Dollar Stop Loss Claim Decisions That Matter

Are you an experienced Stop Loss Claims professional who thrives on analyzing complex medical claims, interpreting contract language, and making informed reimbursement decisions?

As a Senior Stop Loss Claims Analyst (Stop Loss Auditor), you'll join a highly respected team where your expertise will directly influence claim outcomes, customer experience, and business results. This is an opportunity to leverage your stop loss knowledge in a collaborative environment that values critical thinking, professional development, and continuous improvement.

This position can either be fully remote (if not within commutable distance to the office) or based in one of our offices:

• Hamilton Square, NJ
• West Hartford, CT
• Marlborough, MA
• Harleysville, PA

We offer hybrid work schedule with 4 days in the office; and 1 day remote where it makes sense to do so.

What you can expect:

• Culture of innovation, teamwork, supportive colleagues and leaders willing to invest in talent
• Internal mobility opportunities
• Visibility to senior leaders and partnership with cross functional teams
• Opportunity to impact change
• Benefits – competitive compensation, paid time off, comprehensive wellness benefits and programs, employer funded health savings account, profit sharing, 401k, paid parental leave, employee stock purchase plan, tuition assistance and professional continuing education

We'll count on you to:

• Review and audit Stop Loss claim submissions to determine reimbursement eligibility
• Analyze complex medical claims and apply contract provisions to claim decisions
• Handle high-severity, challenging, and escalated claim situations independently
• Review medical documentation, plan specifications, and contractual language to support claim determinations
• Document claim rationale with accuracy and consistency
• Resolve claim discrepancies, reconciliation issues, and complex problem cases
• Maintain production and quality standards while managing an assigned claim inventory
• Provide guidance and expertise to internal business partners and claims colleagues
• Mentor and support newer team members
• Help drive best practices and continuous improvement initiatives
• Ensure compliance with HIPAA, ACA, privacy requirements, and other applicable regulations

Qualifications

What you need to have:

• 5+ years of Stop Loss claims, reinsurance claims, or Stop Loss auditing experience
• Strong understanding of Stop Loss contracts, claim reimbursement provisions, and policy interpretation
• Experience evaluating complex medical claims and supporting documentation
• Excellent analytical, problem-solving, and decision-making abilities
• Strong written and verbal communication skills
• Ability to effectively prioritize workloads and manage deadlines independently
• Proficiency with Microsoft Excel and Microsoft Office applications
• High School Diploma

What makes you stand out:

• Deep expertise in Stop Loss reimbursement analysis
• Ability to navigate complex and ambiguous claim situations with confidence
• Process improvement mindset with a focus on operational excellence
• Strong relationship-building skills and ability to influence across teams
• Experience serving as a mentor or subject matter expert
• Passion for delivering accurate, defensible claim decisions

Additional Company Details

We do not accept any unsolicited resumes from external recruiting firms. The company offers a competitive compensation plan and robust benefits package for full time regular employees including: • Base Salary Range: $80,000 - $90,000 • Benefits include: Health, dental, vision, dental, life, disability, wellness, paid time off, 401(k) and generous profit-sharing plan The actual salary for this position will be determined by a number of factors, including the scope, complexity and location of the role; the skills, education, training, credentials and experience of the candidate; and other conditions of employment.

Sponsorship Details

Sponsorship not Offered for this Role