Senior Claims Specialist

Claims Adjudication Specialist

High-dollar claims, dialysis claims, and stop loss claims carry real weight for the organization's bottom line and for the members whose care depends on getting this right. This role sits at the center of that responsibility, reviewing and adjudicating complex claims where accuracy isn't optional and compliance isn't negotiable. Every claim processed correctly protects the organization from costly errors and ensures members get the coverage they're entitled to without delay or dispute. The work demands real command of health insurance guidelines and the ability to navigate multiple claims systems with confidence. Get the details right here, and the ripple effect shows up in client trust, regulatory standing, and the financial health of the entire claims operation.

This role is located in Tempe AZ- all candidates must be able to commute into this location weekly.

Adjudicate high-dollar and specialty claims: Review, analyze, and process complex healthcare, dialysis, and stop loss claims with a level of scrutiny that catches errors before they become liabilities.

Enforce quality and procedural standards: Conduct thorough claim reviews and examinations to confirm every claim is handled in full accordance with company policy and procedure.

Stay current on regulatory and industry standards: Track evolving claims processing guidelines and regulatory requirements so every decision holds up to compliance scrutiny.

Hit production and timeliness targets: Complete claims work within required timeframes while maintaining the production standards the team depends on.

Resolve escalations for the claims team: Serve as a go-to resource for questions and complex claim issues that need a deeper level of expertise.

Validate plan setup and documentation: Review plans, documents, and vendor information to confirm proper system setup, and flag any errors or issues in plan documents, processing, or configuration to management before they escalate.

Manage the stop loss renewal process: Execute renewal-related claims work as directed, keeping the process on track and accurate.

Complete required training on schedule: Stay current on all training requirements to keep skills and compliance knowledge sharp.

Drive follow-through on open items: Track outstanding tasks and inquiries to closure, so nothing falls through the cracks.

Support client and vendor relationships: Serve as a direct point of contact for clients, internal staff, and vendors to keep claims moving and members satisfied.

Education & Experience: Degree in Business, Healthcare Administration, or a related field preferred; equivalent experience considered

4+ years of experience in claims processing, adjudication, or related healthcare/insurance operations

4+ years of experience working across multiple claims processing systems

Healthcare industry background strongly preferred, including experience in health insurance, medical office, billing, admissions, or clinical front-desk settings

Thorough knowledge of medical terminology, including ICD-9, CPT, and HCPCS coding

Proficiency with claims processing systems, Microsoft Office Suite, and reporting tools

Familiarity with insurance database systems a plus

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 people's health

This position offers a base salary range of $22-$25 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

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.