Medical Stop Loss Claims Group Insurance; Remote

Job Classification

Operations - Insurance Operations

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.

• 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.

• Partner in the design, implementation, and optimization of claims technology solutions.
• Provide subject matter expertise to ensure efficient workflows and industry‑leading claims practices.

• Recruit, develop, and lead a high‑performing claims organization.
• Foster a culture of accountability, collaboration, continuous improvement, and professional development.

• 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.

• 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.

• Leverage data, analytics, and technology to improve accuracy, efficiency, and service delivery.
• Drive process improvements that reduce cycle times and enhance the customer experience.

• Ensure adherence to all applicable federal and state regulations, contractual requirements, and internal controls.

• Collaborate across underwriting, implementation, account management, finance, actuarial, and operations teams to deliver seamless end‑to‑end service.

• 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.

• 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.

• 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.

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

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 $ to $. 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,…