Health Claims Stop Loss Specialist

Personify Health, Inc.; United States; Remote; USD 31.000 - 34.000; Vollzeit

Benefits dieser Stelle

Competitive base salary plus benefits

Comprehensive medical and dental

Unlimited PTO

Mental health support

Professional development

Zusammenfassung

Personify Health, Inc. is seeking a Stop Loss Specialist to manage the filing process, assess claim eligibility, and coordinate with carriers and internal teams.

You will build claimant files, track reimbursements, and ensure timely submissions to protect client cash flow. You will serve as the operational core of the filing workflow, maintaining audit-ready records and driving accurate data across the reimbursement process.

Qualifikationen

• High school diploma or GED required; related healthcare/business education a plus.
• Minimum 3 years of related experience in stop loss, claims, or healthcare operations.
• Knowledge of CPT, HCPCS, and ICD-10 codes.
• Proficient in Microsoft Office; ability to read, analyze, and interpret financial reports and contract terms.
• Experience with claims databases or reimbursement tracking systems.

Aufgaben

• Prepare and file stop loss claim submissions within established internal timeframes.
• Build and maintain claimant files across the claim lifecycle.
• Track and recover outstanding reimbursements; generate weekly reports and follow up with carriers.
• Maintain the reimbursement database for leadership and teams.
• Coordinate communication between PBMs and internal stakeholders regarding stop loss claimants.
• Escalate open/disputed items in a timely manner to prevent issues from escalating.

Kenntnisse

Microsoft Office

Financial analysis

Claims systems

Medical terminology

Ausbildung

High school diploma or GED

Tools

Excel

Word

Outlook

Reimbursement tracking systems

Jobbeschreibung

Overview

Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready to be the engine behind accurate, timely stop loss filings that protect clients and recover real dollars?

Why This Role Matters

Stop loss reimbursement doesn't happen automatically — it takes someone who knows how to move a claim from eligibility assessment to filed submission to recovered dollars, without dropping the ball along the way. As a Stop Loss Specialist, you're the operational core of the filing process, managing spec claimants, tracking reimbursements, and keeping carriers and internal teams aligned. The accuracy and timeliness of your work directly affects cash flow, client financial outcomes, and the integrity of Personify Health's stop loss operations. When you do this job well, clients get what they're owed — and the business runs the way it should.

What You'll Actually Do

• Prepare and file stop loss claim submissions: Assess claim eligibility against excess loss policy terms, gather required documents, run reports, and submit spec claimant filings within established internal timeframes.
• Build and maintain claimant files: Create and manage the initial specific file for each claimant, keeping records accurate, complete, and audit-ready throughout the claim lifecycle.
• Track and recover outstanding reimbursements: Monitor all reinsurance requests to confirm receipt, generate weekly outstanding reimbursement reports, and follow up directly with stop loss carriers to drive resolution.
• Maintain the reimbursement database: Keep the database of specific reimbursement requests current and accurate, ensuring leadership and teammates have reliable data to work from.
• Serve as the liaison between PBMs and internal clients: Coordinate communication between pharmacy benefit managers and internal stakeholders as it relates to stop loss claimants, keeping all parties informed and aligned.
• Escalate open and disputed items: Keep your supervisor informed of unresolved, disputed, or at-risk items in a timely manner so issues get addressed before they compound.

Qualifications

What You Bring to Our Team

Education & Experience:

• High school diploma or GED required; additional education in healthcare, business, or a related field a plus
• Minimum 3 years of related experience in stop loss, claims, or healthcare operations; equivalent combination of education and experience considered
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes

Technical Skills:

• Proficient in Microsoft Office, including Word, Excel, and Outlook
• Ability to read, analyze, and interpret financial reports, legal documents, and stop loss contract terms
• Experience working with claims databases or reimbursement tracking systems
• Ability to apply mathematical and statistical reasoning to financial data and reimbursement calculations

Benefits

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Unlimited PTO—rest and recharge time is non-negotiable
• Mental health support, retirement planning, and financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact on people's health

Want the full picture?Visitpersonifyhealthbenefits.comto explore our complete benefits package, wellness programs, and other employee perks.

Compensation: This position offers a base salary range of $22.65 - $25.00, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

Our Commitment:Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe:Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them [e-mail]. View all legitimate openings atpersonifyhealth.com/careers.