Health Claims Stop Loss Specialist Job at Personify Health

Health Claims Stop Loss Specialist

Personify Health

Location:
United States

Category:
Insurance

Contract Type:
Not provided

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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Job Link Share:

Health Claims Stop Loss Specialist

Personify Health

Location:
United States

Category:
Insurance

Contract Type:
Not provided

Salary:

Job Description:

Job Responsibility:

Requirements:

Nice to have:

Additional Information:

Job Posted:
January 02, 2026

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Job Description:

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Requirements:

Nice to have:

Additional Information:

Job Posted:January 02, 2026

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