Remote, United States

We’re Personify Health. We’re the first and only personalized health platform company to bring health, wellbeing, and navigation solutions together. Helping businesses optimize investments in their members while empowering people to meaningfully engage with their health. At Personify Health, we believe in offering total rewards, flexible opportunities, and a diverse inclusive community, where every voice matters. Together, we’re shaping a healthier, more engaged future.

Who are you?

The Stop Loss Specialist is responsible for supporting the coordination and filing of specifications, advance funding, and plan year-end closeouts. The incumbent is expected to communicate professionally and respectfully with peers, supervisors, subordinates, markets, customers, and the public. Courtesy and professionalism are key components of success in this role.

In this role you will wear many hats, but your knowledge will be essential in the following:

Prepare Stop Loss claims and applicable documents to determine Stop Loss filing eligibility applicable to the Excess Loss Policy.
Files submissions of spec claimants (running reports, gathering necessary documents and email correspondence), processing all submissions within established internal timeframes.
Coordinate Advanced Funding Requests, with the client and the Stop Loss carrier.
Maintains database of all specific reimbursement requests.
Creates initial Specific File for each claimant, files all submissions in our EDOCS platform.
Coordinates the release of Over Specific, System Hold “on hold” claims.
Acts as the liaison between the PBM’s and internal clients, as it pertains to our Stop Loss claimants.
Keeps immediate supervisor apprised of open or disputed items.
Contributes to daily workflow with regular and punctual attendance.
Performs related or other assigned duties as required or directed.
Monitors all reinsurance requests to ensure receipt of reimbursement.
Generates weekly outstanding reimbursement report and follows up with the Stop Loss carrier.

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

What you bring to the Personify Health team:

In order to represent the best of what we have to offer you come to us with a multitude of positive attributes including:

High school diploma or general education degree (GED) required.
Knowledge of medical terminology, CPT, HCPCS and ICD-10 codes a plus.
Knowledge of insurance database system a plus.
Ability to read, analyze, and interpret common financial reports and legal documents.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Experience with claims/call center health insurance environment a plus.
Experience in self-funded plan administrations a plus.

You also take pride in offering the following Core Skills, Competencies, and Characteristics:

Must be computer literate and knowledgeable in Windows and Microsoft Office environment, including Word, Excel and Outlook.
Strong written and verbal communication skills.
Proficient in Word, Excel, and outlook.
Ability to organize, prioritize, and multitask in a fast-paced/deadline driven environment.
Demonstrate ability to work independently with excellent judgment.
A detail-oriented, analytical, financially minded approach.
Capacity to think creatively and strategically.
Claims processing experience or medical background a plus.
Ability to interact in a professional manner with coworkers, clients.

No candidate will meet every single desired qualification. If your experience looks a little different from what we’ve identified and you think you can bring value to the role, we’d love to learn more about you!

Personify Health is an equal opportunity organization and is committed to diversity, inclusion, equity, and social justice.

In compliance with all states and cities that require transparency of pay, the base compensation for this position ranges from $17.00 to $22.00 per hour. Note that compensation may vary based on location, skills, and experience. This position is eligible for health, dental, vision, mental health and other benefits.

We strive to cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive. Personify Health is committed to driving Diversity, Equity, Inclusion and Belonging (DEIB) for all stakeholders: employees (at each organization level), members, clients and the communities in which we operate. Diversity is core to who we are and critical to our work in health and wellbeing.

Personify Health jobs

Health Claims Stop Loss Specialist