Stop Loss Specialist Job at Personify Health (Covington)

Health Claims Stop Loss Specialist

We're seeking a detail-oriented professional who can support the coordination an...

Location

United States

Salary:

19.00 - 22.00 USD / Hour

Personify Health

Expiration Date

Until further notice

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

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

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

Fulltime

New

Clinical Specialist, Quality Management I

Who We Are: Because health is personal. That's why Personify Health created the ...

Location

United States

Salary:

60600.00 - 91000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

Active, unrestricted Registered Nurse (RN) license required
Basic computer literacy
The ability to work on multiple screens, and proficient typing skills
Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, and Outlook
Ability to speak clearly and convey complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others
Ability to work independently and utilize written resources to problem solve
After training with our training department and 1.5 months ramp (3 months total), must have and be able to work in: Teams on and off camera, SharePoint, Drives as needed, VPN, UM Web or Health Notes, El Dorado, Quick Links, GIAS, ADP, Confluence, Phone system with headset, Smartsheet
Knowledge of medical claims and ICD-10, CPT, HCPCS coding
Excellent verbal and written communication skills for upward and downward conversations
Level I: In-depth knowledge of applicable regulations and accreditation standards (HIPAA, CMS requirements as applicable, NCQA, URAC)

Job Responsibility

Ensure compliance with state, federal, and accreditation requirements (e.g., HIPAA, CMS, NCQA, URAC, ERISA, as applicable)
Conduct internal and external audits of UM/CM/CDM processes and documentation
prepare audit files, findings, and corrective action recommendations
Identify quality and compliance risks and collaborate with cross-functional partners on mitigation and resolution
Review and support SOPs and workflows to ensure regulatory alignment and operational clarity
Support external audit readiness activities, including NCQA and URAC evidence preparation and maintenance
Develop, maintain, and deliver role-based training curriculum aligned to compliance standards, quality goals, and operational workflows
Conduct onboarding and orientation to prepare staff for assigned UM/CM/CDM functions
Deliver training using multiple modalities (virtual, self-paced, and one-on-one coaching) tailored to adult learners
Ensure training covers applicable processes such as case initiation and closure, documentation standards, high-dollar case monitoring, stop-loss notification, administrative support, customer service, and productivity expectations

What we offer

Competitive base salary and benefits effective day one
Comprehensive medical and dental through our own health solutions (yes, we use what we build)
Unlimited PTO—rest 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

Fulltime

Claims Review Specialist

We're seeking a detail-oriented professional who can support the coordination an...

Location

United States , Tempe

Salary:

20.00 - 30.00 USD / Hour

Personify Health

Expiration Date

Until further notice

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

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

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

Fulltime

Fraud Specialist

We are looking for a Fraud Specialist to support fraud prevention and case resol...

Location

United States , Rochester

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

At least 1 year of experience in fraud investigations, banking, compliance, business finance, or a comparable environment.
Knowledge of fraud prevention practices, financial risk review, and regulatory or policy-driven procedures.
Ability to conduct research, evaluate documentation, and make informed decisions based on available facts and risk indicators.
Experience handling sensitive information with discretion and in accordance with legal and compliance standards.
Strong written and verbal communication skills for working with clients, financial institutions, and cross-functional business partners.
Proficiency in case tracking, reporting, and maintaining accurate records for trend analysis and audit support.

Job Responsibility

Examine flagged clients and transactions to identify elevated risk, confirm patterns of suspicious behavior, and help stop potentially fraudulent activity before losses occur.
Investigate reports involving check-related fraud, including altered or unauthorized items, and partner with business contacts to guide resolution steps and document outcomes.
Support cases involving exposure of sensitive personal information by following regulatory requirements, coordinating appropriate next steps, and communicating available remediation options.
Assess applicants or new clients who do not pass authentication checks by conducting research into legitimacy, financial standing, and potential risk indicators.
Record fraud incidents accurately in centralized tracking tools to support reporting, pattern analysis, and information sharing across fraud prevention efforts.
Work with financial institutions and internal stakeholders to assist with account restriction, fund recovery efforts, and other actions intended to limit losses.
Provide practical guidance to clients and internal partners on fraud prevention measures, response procedures, and sound security practices.
Compile case details and trend data for recurring reporting needs, helping the team monitor fraud activity and identify areas requiring additional controls.

What we offer

medical
vision
dental
life and disability insurance
company 401(k) plan

Fraud Specialist

We are looking for a Fraud Specialist to support risk management efforts by iden...

Location

United States , Rochester

Salary:

Not provided

Robert Half

Expiration Date

Until further notice

Requirements

Associate degree in Criminal Justice, Economic Crime Investigation, Finance, Business, or a related field
At least 1 year of experience in fraud investigations, banking, compliance, business finance, or a closely related area
Working knowledge of fraud prevention, financial crime controls, and risk mitigation practices
Ability to research account activity, evaluate suspicious patterns, and make sound decisions based on available information
Familiarity with policies, procedures, and regulatory considerations related to fraud, privacy, and financial transactions
Strong written and verbal communication skills with the ability to work effectively across internal teams and external partners
Experience maintaining accurate case records, preparing reports, and tracking statistics for trend analysis

Job Responsibility

Examine high-risk client profiles and transaction activity flagged by fraud prevention controls, and take action to stop potentially harmful activity before losses occur
Investigate reported fraud incidents, including altered or improperly endorsed checks, while coordinating with internal stakeholders to support timely resolution
Document case details in centralized tracking systems so information can be used for reporting, trend analysis, and broader fraud prevention efforts
Partner with financial institutions to help secure affected accounts and support recovery efforts when unauthorized activity is identified
Review situations involving potential exposure of sensitive personal information and guide appropriate response steps in line with company policy and legal requirements
Assess onboarding exceptions when clients do not pass authentication checks, using research tools to confirm legitimacy and determine appropriate risk mitigation measures
Provide practical guidance to internal teams and clients on fraud prevention practices, incident handling procedures, and next-step resolution options
Compile and monitor incident metrics to identify patterns, recurring threats, and areas where fraud controls can be strengthened

What we offer

Medical, vision, dental, and life and disability insurance
Enrollment in company 401(k) plan
Free online training
Access to top jobs
Competitive compensation

Fulltime

Senior Manager, Global Benefits

PerkinElmer is seeking an experienced Global Benefits Manager to join our Total ...

Location

United States , Remote

Salary:

132500.00 - 150000.00 USD / Year

PerkinElmer

Expiration Date

Until further notice

Requirements

Bachelor’s degree in business, finance, human resources, or a related field
10+ years of progressive benefits experience, with significant depth in US self-insured health plan design, administration, and strategy
2+ years of global benefits administration and familiarity with global pooling
CEBS (Certified Employee Benefit Specialist) or CBP (Certified Benefits Professional) designation preferred
Demonstrated experience managing consultant relationships and holding external partners accountable for performance and value delivery
Strong command of US benefits regulatory compliance, including ERISA, ACA, HIPAA, COBRA, FMLA, and related requirements
Experience managing open enrollment end-to-end, including testing and communications
Analytically strong — able to work with claims data, cost trend analysis, and financial modeling
comfortable presenting to senior leadership

Job Responsibility

Serve as primary owner of the US self-insured medical, prescription drug benefit and dental programs, with deep understanding of plan funding, claims administration, and stop-loss structure
Partner with the US consultant (WTW) and third-party administrators to manage plan performance, cost trends, and utilization, bringing forward proactive, creative recommendations to reduce trend
Own and manage relationships with all US benefits vendors including medical, dental, vision, life, disability, EAP and voluntary
Lead annual plan design review and renewal strategy in close partnership with WTW
Own the annual open enrollment process end-to-end
Develop and execute a communications strategy that is employee-centered
Create and maintain employee-facing benefit resources including guides, orientation, FAQs and change communications
Partner with HR Technology and benefits administration vendor to ensure accurate plan configuration
Act as the escalation point for complex employee benefits issues and appeals
Ensure plan documents, SPDs, and legal notices are accurate, current, and compliant

Fulltime

Stylist

From Aisle to Algorithm and for All Life’s Moments, at David’s Bridal, we empowe...

Location

United States , Burlington

Salary:

Not provided

David's Bridal

Expiration Date

Until further notice

Requirements

High school diploma or an equivalent degree
Having 1 -2 years prior retail experience in an apparel, service or specialty store environment
prior experience with computerized POS system is preferred

Job Responsibility

Welcome all customers with genuine, friendly enthusiasm over the phone and in person, communicate clearly and concisely adapting style to suit customers
Use all systems to manage the customer flow to deliver 5-star customer experience (Appointments/Customers/Point of sale system)
Use iPad tools to research and enthusiastically communicate this information to the customer
Responsible for providing exceptional service to multiple customers at one time and contribute to the store achievement of 5-Star Customer Service
Proactively address customer concerns with confidence
Know when to escalate and partner with leadership team
Prepare for customer appointments by reviewing the customer profiles, favorites and preparing a fitting room
Build a relationship by welcoming customers to the store, asking questions and listening to understand customer expectations and needs (emotional and practical)
Strive to identify the perfect gown/dress in the customer’s first three try-ons
Review Timeline Calendar and set future appointments aligning to customer needs

What we offer

Rewarding Environment and Competitive Pay
Team Bonus
Dayforce Wallet – Get Paid Early
Referral Incentive Program
Generous Dream Maker Discount After First Pay Period
Vision Care
Supplemental Insurances- Critical Illness, Hospital Indemnity and Accidental Injury
401K Program
Discount for Identity Theft Protection
Discounts for Home and Auto Insurance

Parttime

Clinical Specialist, Quality Management and Training

The Clinical Compliance & Quality Specialist is responsible for ensuring regulat...

Location

United States

Salary:

60600.00 - 91000.00 USD / Year

Personify Health

Expiration Date

Until further notice

Requirements

In-depth knowledge of state and federal regulations, including HIPAA, CMS, NCQA, and URAC
Ability to interpret and apply evidence-based guidelines and accreditation standards to clinical operations
Skilled in conducting internal and external audits of clinical programs
Proficient in case file preparation, SOP review, and audit mark-up
Capable of producing detailed audit reports and recommending corrective actions
Excellent analytical thinking and problem-solving abilities
Able to identify compliance risks and propose mitigation strategies
Uses written resources independently to resolve issues
Exceptional attention to detail in reviewing clinical documentation and audit trails
Maintains accurate records and ensures data integrity

Job Responsibility

Ensure compliance with state, federal, and accreditation standards, including ERISA, NCQA, URAC, and HIPAA
Conduct internal and external audits of clinical programs, prepare detailed reports, participate in case file preparation and mark-up for audits
Monitor clinical trial activities to ensure protocol adherence and regulatory alignment
Identify and manage risks related to clinical quality and compliance, review and approve Standard Operating Procedures (SOPs), and collaborate with cross-functional teams to resolve quality issues and implement improvements
Train clinical staff on regulatory requirements, quality standards, and department objectives
Develop and maintain evidence-based training materials and software tools, and deliver training in various modalities (classroom, virtual, self-learning, and one-on-one) to adult learners with different levels of experience
Training topics include case identification and creation, stop loss notification, administrative support, monitoring high-dollar cases, case closure, documentation, customer service excellence, and productivity expectations
Track and report training activities and employee progress, updating department leadership on staff who are not meeting expectations
Participate in quality audit programs and conduct monthly sample quality analysis audits to identify gaps and training opportunities
Support corrective action plans as directed by management and provide comprehensive follow-up

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, 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

Fulltime

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Stop Loss Specialist

Job Description

Job Responsibility

Requirements

What we offer

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