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Health Claims Stop Loss Specialist

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Personify Health

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Location:
United States

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Category:
Insurance

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Contract Type:
Not provided

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Salary:

19.00 - 22.00 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. As our Stop Loss Specialist, 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:
  • Comprehensive medical and dental coverage through our own health solutions
  • Mental health support and wellness programs designed by experts who get it
  • Flexible work arrangements that fit your life
  • Retirement planning support to help you build real wealth for the future
  • Basic Life and AD&D Insurance plus Short-Term and Long-Term Disability protection
  • Employee savings programs and voluntary benefits like Critical Illness and Hospital Indemnity coverage
  • Professional development opportunities and clear career progression paths
  • Mentorship from industry leaders who want to see you succeed
  • Learning budget to invest in skills that matter to your future
  • Competitive base salary that rewards your success
  • PTO policy because rest and recharge time is non-negotiable
  • Benefits effective day one

Additional Information:

Job Posted:
January 02, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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