Claims Review Specialist

Who We Are

Because health is personal. Thats 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.

Learn even more about the work that drives us at .

Why This Role Matters

Were seeking a detail-oriented professional who can support the coordination and filing of Stop Loss claims Advance Funding requests and Plan Year End Closeouts. Youll 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.

What makes this role different:

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

What Youll Actually Do

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.

Youll 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 Our Team

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 peoples health

Want the full pictureVisit 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. Youre 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. View all legitimate openings at Experience:

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