Stop Loss Training & Reimbursement Leader

Personify Health, Inc.; Oregon; Hybrid; USD 65,000 - 73,000; Full time

Benefits offered by this job

Competitive base salary

Medical and dental benefits

Unlimited PTO

Mental health support

Retirement planning

Professional development

Mission-driven culture

Job summary

Personify Health, Inc. is seeking a Stop Loss Lead to act as the department’s technical authority. You’ll ensure eligible reimbursements are submitted, tracked, and collected, audit regularly, and drive process improvements that speed and clean up claim handling.

You’ll train and coach the team while improving workflows and reporting, contributing to client outcomes and departmental growth. The role emphasizes contract interpretation, reimbursement administration, and strong data analysis to

Qualifications

• Education & Experience: High School Diploma or equivalent required; Associate’s or Bachelor’s degree preferred
• 3-5 years of experience in stop loss, self-funded health plan administration, claims, or related healthcare required
• Advanced claims processing and reimbursement experience strongly preferred
• Experience interpreting stop loss contracts and plan documents preferred
• Experience auditing, quality reviews, or process improvement initiatives preferred
• Experience training or mentoring team members preferred
• Technical Skills: Advanced knowledge of stop loss administration, reimbursement processes, and contract interpretation
• Working knowledge of medical terminology and CPT, HCPCS, and ICD-10 coding (preferred)
• Proficiency in Microsoft Excel, Word, Outlook, and reporting tools
• Auditing and data analysis skills, including identifying trends and building data-driven recommendations

Responsibilities

• Act as the department’s subject matter expert on administration, reimbursement, and contract interpretation, giving the team a trusted source for answers on complex questions.
• Dig into contracts and carrier requirements: Review stop loss contracts, plan documents, and carrier requirements in depth to ensure compliance and capture every reimbursement opportunity available.
• Drive reimbursements to resolution: Support the submission, tracking, and reconciliation of stop loss claims, and work aging items, carrier inquiries, disputes, and escalated cases through to closure.
• Audit for quality: Conduct regular reviews of claim submissions, reimbursement tracking, documentation, and correspondence to confirm accuracy and completeness, then report results and performance metrics to leadership.
• Turn findings into fixes: Spot recurring errors, trends, and process gaps in audit results, develop corrective action recommendations, and partner with leadership to put them in place.
• Build and coach the team: Onboard new Stop Loss Specialists, create and maintain training materials and standard operating procedures, and deliver coaching and refresher sessions that close knowledge gaps.
• Improve how we work: Evaluate workflows, lead or support process improvement initiatives, and help roll out new tools and best practices, including testing and validating system updates.
• Own reporting and audit readiness: Review and help prepare monthly stop loss and reimbursement reporting and carrier submissions, support internal and external audit requests, and keep documentation accurate and current.
• Step in where it counts: Process stop loss claims and handle related operational work when workflow demands require it, and contribute to special projects that advance department goals.

Job description

Personify Health, Inc. is seeking a Stop Loss Lead to act as the department’s technical authority. You’ll ensure eligible reimbursements are submitted, tracked, and collected, audit regularly, and drive process improvements that speed and clean up claim handling.

You’ll train and coach the team while improving workflows and reporting, contributing to client outcomes and departmental growth. The role emphasizes contract interpretation, reimbursement administration, and strong data analysis to