Claims Review Specialist
Personify Health, Tempe, AZ, United States
Personify Health Stop Loss Specialist
Because health is personal. That's why Personify Health created the first and only personalized health platformbringing 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.
Responsibilities
We're seeking a detail-oriented professional who can support the coordination and filing of Stop Loss claims, Advance Funding requests, and Plan Year End Closeouts. As our Stop Loss Specialist, you'll serve as the critical liaison between clients, Stop Loss carriers, and internal teams while ensuring timely processing of specific reimbursement requests and maintaining comprehensive tracking of all Stop Loss activities.
This role is located in Tempe AZ- all candidates must be able to commute into this location weekly.
Financial protection focus: Determine Stop Loss filing eligibility for claims applicable to Excess Loss Policy, directly impacting client financial protection
Cross-functional coordination: Act as liaison between PBMs and internal clients for Stop Loss claimants while coordinating Advanced Funding Requests
Process ownership: Maintain database of all specific reimbursement requests while creating and managing initial Specific Files for each claimant
Compliance tracking: Monitor all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reports
Prepare Stop Loss submissions: Analyze Stop Loss claims and applicable documents to determine filing eligibility under Excess Loss Policy while processing all submissions within established timeframes.
Coordinate funding requests: Manage Advanced Funding Requests with clients and Stop Loss carriers while maintaining comprehensive database of all specific reimbursement requests.
Manage documentation systems: Create initial Specific File for each claimant and file all submissions in EDOCS platform while coordinating release of Over Specific, System Hold claims.
Serve as liaison: Act as connection point between PBMs and internal clients for Stop Loss claimants while maintaining professional communication with all stakeholders.
Monitor reimbursements: Track all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reimbursement reports and following up with carriers.
Support plan year activities: Assist with Plan Year End Closeouts while keeping immediate supervisor apprised of open or disputed items requiring attention.
Maintain workflow excellence: Contribute to daily workflow with regular, punctual attendance while performing related or assigned duties as required.
Qualifications
The foundational experience:
High school diploma or general education degree (GED) required
Minimum 3 years related experience and/or training, or equivalent combination of education and experience
Completion of training programs through HIPAA, ICA and/or LOMA, and continuing education courses relative to Stop Loss preferred
The technical expertise:
Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
Computer literacy with proficiency in Windows and Microsoft Office environment (Word, Excel, Outlook)
Knowledge of insurance database systems preferred
Experience with EDOCS platform or similar documentation management systems
The analytical competencies:
Detail-oriented, analytical, financially minded approach to Stop Loss coordination
Ability to read, analyze, and interpret common financial reports and legal documents
Capability to work with mathematical concepts such as probability and statistical inference
Skills to apply concepts like fractions, percentages, ratios, and proportions to practical situations
The professional qualities:
Strong written and verbal communication skills for professional interaction with diverse stakeholders
Ability to organize, prioritize, and multitask in fast-paced environment
Demonstrate ability to work independently with excellent judgment and decision-making
Capability to respond to inquiries or complaints from customers, regulatory agencies, or business community members
Ability to effectively present information to top management, public groups, and boards of directors
Problem-solving skills to deal with variety of concrete variables in situations with limited standardization
Capacity to interpret instructions furnished in written, oral, diagram, or schedule form
Professional, respectful, and courteous approach in all position-related conduct
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 PTOrest 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 $20.00 - $30.00, 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 thrivebecause 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 talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.
Because health is personal. That's why Personify Health created the first and only personalized health platformbringing 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.
Responsibilities
We're seeking a detail-oriented professional who can support the coordination and filing of Stop Loss claims, Advance Funding requests, and Plan Year End Closeouts. As our Stop Loss Specialist, you'll serve as the critical liaison between clients, Stop Loss carriers, and internal teams while ensuring timely processing of specific reimbursement requests and maintaining comprehensive tracking of all Stop Loss activities.
This role is located in Tempe AZ- all candidates must be able to commute into this location weekly.
Financial protection focus: Determine Stop Loss filing eligibility for claims applicable to Excess Loss Policy, directly impacting client financial protection
Cross-functional coordination: Act as liaison between PBMs and internal clients for Stop Loss claimants while coordinating Advanced Funding Requests
Process ownership: Maintain database of all specific reimbursement requests while creating and managing initial Specific Files for each claimant
Compliance tracking: Monitor all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reports
Prepare Stop Loss submissions: Analyze Stop Loss claims and applicable documents to determine filing eligibility under Excess Loss Policy while processing all submissions within established timeframes.
Coordinate funding requests: Manage Advanced Funding Requests with clients and Stop Loss carriers while maintaining comprehensive database of all specific reimbursement requests.
Manage documentation systems: Create initial Specific File for each claimant and file all submissions in EDOCS platform while coordinating release of Over Specific, System Hold claims.
Serve as liaison: Act as connection point between PBMs and internal clients for Stop Loss claimants while maintaining professional communication with all stakeholders.
Monitor reimbursements: Track all reinsurance requests to ensure receipt of reimbursement while generating weekly outstanding reimbursement reports and following up with carriers.
Support plan year activities: Assist with Plan Year End Closeouts while keeping immediate supervisor apprised of open or disputed items requiring attention.
Maintain workflow excellence: Contribute to daily workflow with regular, punctual attendance while performing related or assigned duties as required.
Qualifications
The foundational experience:
High school diploma or general education degree (GED) required
Minimum 3 years related experience and/or training, or equivalent combination of education and experience
Completion of training programs through HIPAA, ICA and/or LOMA, and continuing education courses relative to Stop Loss preferred
The technical expertise:
Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
Computer literacy with proficiency in Windows and Microsoft Office environment (Word, Excel, Outlook)
Knowledge of insurance database systems preferred
Experience with EDOCS platform or similar documentation management systems
The analytical competencies:
Detail-oriented, analytical, financially minded approach to Stop Loss coordination
Ability to read, analyze, and interpret common financial reports and legal documents
Capability to work with mathematical concepts such as probability and statistical inference
Skills to apply concepts like fractions, percentages, ratios, and proportions to practical situations
The professional qualities:
Strong written and verbal communication skills for professional interaction with diverse stakeholders
Ability to organize, prioritize, and multitask in fast-paced environment
Demonstrate ability to work independently with excellent judgment and decision-making
Capability to respond to inquiries or complaints from customers, regulatory agencies, or business community members
Ability to effectively present information to top management, public groups, and boards of directors
Problem-solving skills to deal with variety of concrete variables in situations with limited standardization
Capacity to interpret instructions furnished in written, oral, diagram, or schedule form
Professional, respectful, and courteous approach in all position-related conduct
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 PTOrest 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 $20.00 - $30.00, 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 thrivebecause 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 talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.