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Claims Review Specialist

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Personify Health

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Location:
United States , Tempe

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Category:
Insurance

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Contract Type:
Employment contract

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Salary:

20.00 - 30.00 USD / Hour
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Job Description:

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. 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.

Job Responsibility:

  • 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

Requirements:

  • 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
  • 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
  • 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
  • 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

Nice to have:

  • Completion of training programs through HIPAA, ICA and/or LOMA, and continuing education courses relative to Stop Loss
  • Knowledge of insurance database systems
  • Experience with EDOCS platform or similar documentation management systems
What we offer:
  • Competitive base salary and benefits effective day one
  • Comprehensive medical and dental through our own health solutions
  • Unlimited PTO
  • Mental health support
  • Retirement planning
  • Financial protection
  • Professional development with clear career progression and learning budgets
  • Mission-driven culture

Additional Information:

Job Posted:
May 05, 2026

Employment Type:
Fulltime
Work Type:
On-site work
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