• Receive, log, and validate incoming stop-loss claims and related documentation • Verify eligibility, plan benefits, and stop-loss policy provisions • Accurately enter claim details into the system of record • Maintain electronic claim files for audit and compliance purposes • Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims • Identify cost-containment opportunities and implement strategies with carriers and TPAs • Document audit findings and maintain accurate records in the system • Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams • Offer guidance to clients on claims procedures and coverage issues • Ensure adherence to regulatory requirements, internal controls, and fraud prevention policies • Stay current on industry trends, regulations, and best practices • Identify opportunities to streamline claim intake and processing workflows • Train and mentor junior claims processors on best practices