Stop-Loss Claims & Reimbursement Specialist

Personify Health; EE. UU.; A distancia; USD 31.000 - 34.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive base salary

Benefits from day one

Paid time off

Professional development

Mental health support

Descripción de la vacante

Personify Health is seeking a Stop Loss Specialist to serve as the operational core of our filing process, ensuring accurate eligibility assessments, timely submissions, and prompt reimbursements. You will manage spec claimants, track reimbursements, and keep carriers and internal teams aligned to protect clients’ financial outcomes.

The role requires at least 3 years in stop loss, claims, or healthcare operations, a HS diploma, and strong Excel and data interpretation skills.

Formación

• 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

Responsabilidades

• 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 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 liaison between PBMs and internal clients: Coordinate communication between pharmacy benefit managers and internal stakeholders as it relates to stop loss claimants
• 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

Conocimientos

Microsoft Office

Financial analysis

Claims systems

Stop loss knowledge

Data interpretation

Educación

High school diploma or GED

Herramientas

Claims databases

Reimbursement tracking systems

Descripción del empleo

Personify Health is seeking a Stop Loss Specialist to serve as the operational core of our filing process, ensuring accurate eligibility assessments, timely submissions, and prompt reimbursements. You will manage spec claimants, track reimbursements, and keep carriers and internal teams aligned to protect clients’ financial outcomes.

The role requires at least 3 years in stop loss, claims, or healthcare operations, a HS diploma, and strong Excel and data interpretation skills.