Medical Stop Loss Claims Group Insurance

Job Classification:

Operations - Insurance Operations

Help Lead the Future of Medical Stop Loss Claims at Prudential

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. You'll play a critical role in designing our claims operations, driving innovation, and ensuring an exceptional experience for our customers, brokers, consultants, and partners.

Key Responsibilities:

Strategic Leadership

• 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.

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 Prudential's 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.

Qualifications:

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

• Bachelor's degree in Business, Healthcare Administration, or a related field preferred.

What we offer you:

Prudential is required by state specific laws to include the salary range for this role when hiring a resident in applicable locations. The salary range for this role is from $106,000.00 to $174,900.00. Specific pricing for the role may vary within the above range based on many factors including geographic location, candidate experience, and skills.

• 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 $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).

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.

If you need an accommodation to complete the application process, please email [email protected].

If you are experiencing a technical issue with your application or an assessment, please email [email protected] to request assistance.

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