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Remote Stop Loss Insurance Jobs in Texas (NOW HIRING)

CSAA

Job Title Commercial Insurance Consultant, Claims Insights- Remote Requisition Number R7770 ... Formulate datadriven recommendations to improve operational efficiency, loss outcomes, and business ...

DataBank

Insurance Risk Manager (Remote)

Dallas, TX · On-site +1

Analyze loss data, claims trends, and operational processes; maintain the company's risk register ... Insurance Program Management * Manage all corporate insurance programs (property, casualty ...

Jobot

Insurance Defense Attorney

Austin, TX · On-site +1

$160K - $200K/yr

Enjoy hybrid flexibility, combining in-office collaboration with remote work convenience ... You can reply STOP to cancel and HELP for help. You can access our privacy policy here: jobot.com ...

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All JobsStop Loss Insurance JobsRemote Stop Loss Insurance JobsRemote Stop Loss Insurance Jobs in Texas

Remote Stop Loss Insurance information

What are the key skills and qualifications needed to thrive as a Remote Stop Loss Insurance Specialist, and why are they important?

To excel as a Remote Stop Loss Insurance Specialist, you need expertise in health insurance underwriting, risk assessment, and policy analysis, often supported by a background in insurance or finance. Familiarity with industry-standard claims management systems, CRM platforms, and regulatory compliance tools is essential. Strong analytical thinking, attention to detail, and effective written communication are crucial soft skills for success in a remote environment. These abilities ensure accurate risk evaluation, regulatory adherence, and clear client interactions, which are critical for managing high-value stop loss insurance contracts.

What is remote stop loss insurance?

Remote stop loss insurance is a type of coverage designed to protect self-funded employers from large or catastrophic claims, but managed and administered through digital or remote platforms. This insurance reimburses employers for claims that exceed a predetermined limit, helping them manage risk and avoid significant financial loss. The 'remote' aspect refers to the use of online tools and services for policy management, claims processing, and communication, allowing for flexible and efficient administration without the need for in-person meetings. This is particularly beneficial for companies with distributed teams or those seeking streamlined, technology-driven solutions.

What is the difference between Remote Stop Loss Insurance vs Remote Underwriter?

AspectRemote Stop Loss InsuranceRemote Underwriter
CredentialsInsurance licenses, actuarial knowledgeInsurance licenses, underwriting certifications
Work EnvironmentInsurance companies, brokers, remoteInsurance companies, remote or office
Industry UsageHealth and self-funded plansInsurance policy assessment and risk evaluation

Remote Stop Loss Insurance professionals focus on providing coverage for self-funded health plans, managing risk, and setting policy terms. Remote Underwriters evaluate insurance applications, assess risks, and determine policy eligibility. While both roles require insurance knowledge and licenses, Stop Loss Insurance specialists concentrate on risk management for health plans, whereas Underwriters focus on evaluating individual applications. Understanding these differences helps clarify career paths and job expectations in the insurance industry.

What are some common challenges faced by professionals working in remote stop loss insurance roles?

One common challenge in remote stop loss insurance roles is maintaining clear and effective communication with underwriters, brokers, and clients, since much of the collaboration happens virtually. Additionally, staying updated on changing regulations and market trends requires proactive self-learning and digital resourcefulness. Managing sensitive data securely and ensuring timely turnaround on complex claims or policy analysis can also be demanding when working remotely. Building strong relationships with team members and clients, despite the lack of in-person interaction, is key to long-term success in this field.
What are the most commonly searched types of Stop Loss Insurance jobs in Texas? The most popular types of Stop Loss Insurance jobs in Texas are:
What are popular job titles related to Remote Stop Loss Insurance jobs in Texas? For Remote Stop Loss Insurance jobs in Texas, the most frequently searched job titles are:
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What cities in Texas are hiring for Remote Stop Loss Insurance jobs? Cities in Texas with the most Remote Stop Loss Insurance job openings:
Remote Stop Loss Insurance jobs near you

Senior Claims Analyst - Hospital Bill Review

SmartLight Analytics

Plano, TX • On-site, Remote

Full-time

Posted 16 days ago

Job description

We are seeking an experienced Senior Claims Analyst with deep expertise in hospital claims adjudication, stop loss reporting, high-cost/catastrophic claims, and DRG (Diagnosis-Related Group) reimbursement methodology. This individual will analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities, then work directly with claims administrators on behalf of our ASO clients to secure claim adjustments, recoveries, and repricing.
This is a highly analytical, client-facing role requiring both technical claims expertise and strong negotiation/communication skills.
Key Responsibilities
Claims Analysis & Review
  • Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy.
  • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement.
  • Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments.
  • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement.
Stop Loss & High-Cost Claims Expertise
  • Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure.
  • Coordinate with stop loss carriers and reinsurers as needed to ensure adjustments and recoveries are properly reflected in stop loss reimbursement calculations.
  • Identify claims nearing or exceeding specific deductible thresholds and prioritize review accordingly.
Client Advocacy & Claims Administrator Negotiation
  • Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy.
  • Prepare clear, well-documented findings packages (clinical, contractual, and coding rationale) to support requested claim adjustments and appeals.
  • Lead or support negotiations with claims administrators to reach adjusted payment resolutions.
  • Track disputes through resolution, escalating unresolved cases appropriately and maintaining strong working relationships with TPA claims and provider relations teams.
Data & Reporting
  • Analyze large claims data sets to identify trends, outlier claims, and systemic overpayment patterns across client populations.
  • Build and maintain claim tracking logs, savings reports, and client-facing summaries of identified and recovered savings.
  • Partner with internal data/analytics teams to refine claim-flagging logic and improve identification of high-value review opportunities.
Required Qualifications
  • 5+ years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity, with direct exposure to self-funded/ASO plans.
  • Strong working knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS coding, and hospital chargemaster structures.
  • Demonstrated understanding of stop loss insurance, including specific/aggregate deductibles, laser provisions, and how claim adjustments impact stop loss reimbursement.
  • Experience analyzing high-cost/catastrophic claims and identifying overpayment or billing error patterns.
  • Prior experience interacting with or negotiating against TPAs, insurance carriers, or claims administrators on disputed claims.
  • Proficiency with claims data analysis tools (Excel required; SQL, Access, or claims analytics platforms a plus)
  • Excellent written and verbal communication skills, with the ability to build persuasive, well-supported adjustment requests and appeals.
  • Strong attention to detail and ability to manage a high volume of complex claims simultaneously.
Preferred Qualifications
  • Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Bill Review Specialist, or similar credential.
  • Prior experience at a TPA, insurance carrier, hospital billing/coding department, or payment integrity/cost containment vendor.
  • Familiarity with reference-based pricing (RBP), Medicare fee schedules, and out-of-network claims repricing.
  • Nursing background (RN) or clinical coding background is a plus for clinical validation of DRG and medical necessity issues.
What Success Looks Like
  • Consistent identification of material overpayments and billing errors on high-cost hospital claims.
  • Strong track record of securing favorable claim adjustments through negotiation with claims administrators.
  • Clear, professional communication that strengthens client trust and TPA relationships.
  • Measurable contribution to client savings and stop loss cost containment.

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