Health Claims Stop Loss Specialist
总结 我们是谁 因为健康是个人的。这就是为什么 Personify Health 创建了第一个和唯一的个性化的卫生平台将医疗计划管理，整体福祉解决方案和综合护理导航放在一个地方。我们提供数据驱动的解决方案给雇主，医疗计划和保健系统，从而降低成本并实际上改善健康结果。我们的团队共同致力于赋予人们更好的生活能力。在 personifyhealth.com 了解更多关于推动我们的工作。责任准备成为保护客户和恢复真正美元的精确及时停止损失文件背后的引擎？为什么这个角色重要？停止损失退款不会自动发生需要一个知道如何从资格评估移动索赔到恢复的美元提交申请的人，而没有在路上丢掉球。作为 Stop Loss 专家，你是申报过程的运营核心，管理规范索赔者，跟踪退款，并保持运输商和内部团队一致。你的工作的准确性和及时性直接影响现金流，客户财务结果以及 Personify Health 的止损操作的完整性。当你做好这项工作时，客户得到了他们应该应有的东西，业务就会按照其所需的方式进行。你实际上将做什么 · 准备和提交停止损失索赔申请：根据过剩损失政策条款评估索赔的资格，收集所需文件，运行报告并在既定内部时间框架内提交要求申报人的具体档案。· 建立和维护索赔人档案：为每个索赔人创建和管理最初的特定档案，保持记录精确，完整和审计准备整个索赔生命周期。·追踪和收回未偿还款：监测所有再保险请求确认收到，生成每周未偿还付报告，并直接跟进止损承运营商以推动解决方案。· 维持退款数据库：保持具体退款请求的数据库最新和准确，确保领导层和队友有可靠的数据来工作。·作为 PBM 与内部客户之间的联系人：协调药房福利管理者和有关停止损失申请者的内部利益相关方之间的沟通，让所有当事人了解并一致。·扩大开放和争议项目：让你的监管人员知道未解决的问题，纠纷或问题；
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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? Visit personifyhealthbenefits.com to 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 to . View all legitimate openings at personifyhealth.com/careers.
Originally posted on Himalayas