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Salary: USD 80,000 - 90,000 / annual
Yuzu is a tech-enabled Third Party Administrator (TPA) that powers innovative health plans through care navigation, capitated primary care, and real-time payments. The Stop Loss Specialist coordinates all stop loss insurance activities for self-funded employer groups, serving as the primary liaison between the TPA, stop loss carriers, brokers, and internal departments.
Key responsibilities include preparing and submitting initial and ongoing stop loss claims per carrier requirements, reviewing claims data to validate eligibility, benefits, accumulators, and billing accuracy before submission. The role tracks reimbursements, reconciles payments against expected recoveries, and maintains timely follow-up with carriers on outstanding items.
The specialist identifies potential stop loss claimants through daily/weekly high-dollar reporting, monitors claims approaching specific deductibles, and maintains accurate accumulation logs. Policy and contract administration duties include reviewing stop loss policies for adherence to contract terms, exclusions, and filing deadlines.
Coordination responsibilities span serving as primary contact for stop loss carriers and employer groups on claim statuses and policy questions, collaborating with Claims team members to gather documentation, and maintaining accurate, secure records of all claims and reimbursement records to meet audit and compliance standards.
Ideal candidates possess 2–5 years of experience in healthcare claims processing, preferably within a mid-sized TPA in the self-funded space. Strong understanding of medical claims, ICD-10, CPT codes, billing rules, and plan document interpretation is essential. Knowledge of stop loss concepts (specific/aggregate deductibles, lasers, reimbursement timelines), proficiency with claims platforms and Excel, and excellent analytical and problem-solving skills are highly valued. The role demands exceptional attention to detail, strong communication abilities, and effective time management in a fast-paced environment.
