Healthcare Stop Loss 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

Stop loss reimbursement doesnt 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 youre 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 Healths stop loss operations. When you do this job well clients get what theyre owed and the business runs the way it should.

What Youll 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.

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)
• Paid Time Offrest 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 $22.00-$25.00 per hour 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.

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