Health Plans Claims Processor

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. 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. 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.

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: Keep your supervisor informed of unresolved, disputed, or at-risk items in a timely manner so issues get addressed before they compound.

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; Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes

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

Comprehensive medical and dental through our own health solutions (yes, we use what we build)

Mental health support, retirement planning, and financial protection

This position offers a base salary range of $21.00-$24.00 per hour, depending on location, skills, and experience. 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.

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