Senior High-Dollar Claims Specialist

Personify Health, Inc.; Northern (KY); Hybrid; USD 30,000 - 34,000; Full time

Benefits offered by this job

Competitive benefits

PTO (Paid Time Off)

Mental health support

Career development

Diversity & inclusion

Job summary

Personify Health, Inc. is seeking a claims professional to adjudicate high-dollar and specialty claims, ensuring accuracy and compliance across complex healthcare scenarios. You will own production targets, guide escalations, and validate plan configurations while supporting clients and vendors so claims move smoothly.

A healthcare background and strong data skills are essential. The role emphasizes regulatory awareness, teamwork, and delivering reliable outcomes in a fast-paced environment with

Qualifications

• Degree in Business, Healthcare Administration, or related field preferred; equivalent work experience considered
• 4+ years of experience in claims processing, adjudication, or related healthcare operations
• 4+ years across multiple claims processing systems
• Healthcare industry background preferred (health insurance, medical office, billing, or clinical operations)

Responsibilities

• Adjudicate high-dollar and specialty claims: review and process complex healthcare, dialysis, and stop loss claims from intake through resolution
• Enforce quality and compliance standards: ensure decisions comply with policy and regulations
• Own production and turnaround targets: complete claims work within required timeframes with accuracy
• Guide the claims team through escalations as needed
• Validate plan setup and documentation to confirm correct system configuration
• Flag risk early by identifying errors in plan documents or processing
• Drive the stop loss renewal process as directed
• Stay current on regulatory landscape with required trainings
• Deliver direct client and vendor support to resolve questions and move cases forward
• Support strategic projects from supervisors and managers

Skills

Claims processing

Adjudication

Healthcare terminology

ICD-9 CPT HCPCS

Microsoft Office

Data analysis

Education

Bachelor’s in Business/Healthcare Administration

Tools

Claims processing systems

Reporting tools

Insurance databases

Job description

Personify Health, Inc. is seeking a claims professional to adjudicate high-dollar and specialty claims, ensuring accuracy and compliance across complex healthcare scenarios. You will own production targets, guide escalations, and validate plan configurations while supporting clients and vendors so claims move smoothly.

A healthcare background and strong data skills are essential. The role emphasizes regulatory awareness, teamwork, and delivering reliable outcomes in a fast-paced environment with