layiq

/la·yiq/adjective

worthy; deserving; fitting; suitable.

A role, opportunity, or path that merits attention, time, and pursuit.

LAYIQ - Stop Loss Claims Manager at Hub International

Claims Administration & Adjudication: Review, evaluate, and adjudicate specific and aggregate stop-loss claims in accordance with policy provisions, contractual terms, and regulatory requirements.
Documentation & Verification: Analyze claim submissions, medical records, and supporting documentation to validate eligibility, accuracy, and reimbursement amounts.
Stakeholder Liaison: Serve as the primary point of contact between employers, TPAs, brokers, and carriers to facilitate clear communication and expedite claim resolution.
High-Cost Claim Management: Monitor claims approaching or exceeding specific deductible thresholds; proactively flag, track, and manage catastrophic and trigger-diagnosis cases.
Compliance Oversight: Ensure all claims handling adheres to applicable federal and state regulations (ERISA, HIPAA, ACA) and internal policies.
Reporting & Analytics: Prepare and present claims reports, loss runs, and trend analyses for internal leadership and external partners; identify cost-driver patterns and recommend mitigation strategies.
Process Improvement: Identify opportunities to streamline workflows, reduce turnaround times, and enhance claim handling quality.
Dispute Resolution: Investigate and resolve disputed, denied, or contested claims, coordinating with legal and clinical resources when escalation is required.
Vendor Management: Oversee relationships with reinsurers, case managers, and cost-containment vendors to ensure performance, accuracy, and contract compliance.
Team Leadership: Mentor, train, and provide technical guidance to claims analysts and support staff; may directly supervise junior team members.
Required Qualifications
Bachelor's degree in Business, Insurance, Risk Management, Healthcare Administration, or a related field (equivalent experience considered).
5+ years of progressive experience in stop-loss, medical, or health insurance claims, with at least 2 years in a senior or supervisory capacity.
Comprehensive knowledge of self-funded health plans, stop-loss contracts (specific and aggregate), and claims adjudication processes.
Strong understanding of medical terminology, ICD/CPT coding, and Usual & Customary (U&C) reimbursement methodologies.
Working knowledge of ERISA, HIPAA, ACA, and other relevant healthcare and insurance regulations.
Proficiency in claims management systems and Microsoft Office Suite (advanced Excel preferred).
Excellent analytical, organizational, and decision-making skills with a high attention to detail.
Strong written and verbal communication skills, with the ability to negotiate and influence across multiple stakeholders.

Stop Loss Claims Manager

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