Health Claims Stop Loss Specialist
Personify Health
Summary
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.
Job description
Why This Role Matters
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.
What You'll Actually Do
- 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.
- Build and maintain claimant files: 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: Coordinate communication between pharmacy benefit managers and internal stakeholders as it relates to stop loss claimants, keeping all parties informed and aligned.
- Escalate open and disputed items: Keep your supervisor informed of unresolved, disputed, or at-risk items in a timely manner so issues get addressed before they compound.
Education & Experience
- 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; equivalent combination of education and experience considered
- Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
Technical Skills
- 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
Requirements
- High school diploma or GED required
- 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
Benefits
- Medical, Dental & Vision
- Paid Time Off
- Mental Health Support
- Retirement Planning
- Financial Protection
- Professional Development
- Learning Budgets
Company overview
Personify Health is a pioneering personalized health platform company that integrates health plan administration, holistic wellbeing solutions, and comprehensive health navigation into a unified digital ecosystem. Founded in 2023 and headquartered in Providence, Rhode Island, the company represents a transformative approach to healthcare by breaking down traditional industry silos and rejecting one-size-fits-all solutions. With approximately 1,001-5,000 employees, Personify Health combines decades of healthcare experience with global operations to deliver an end-to-end platform that proactively addresses individuals' unique health needs across their lifespan. The company's innovative platform leverages data-driven personalization capabilities, science-backed methodologies, and concierge-level clinical services to help businesses optimize their healthcare investments while empowering members to engage more deeply with their health. Personify Health specializes in health plan administration, wellbeing technology, navigation and advocacy, payment integrity, care and condition management, case management, and claims processing. By connecting digital intelligence with human support, the company guides members toward healthier decisions and lower costs, resulting in measurable savings and improved health outcomes for self-funded employers and their workforces. The platform serves employers, health plans, health systems, brokers, and consultants, positioning Personify Health as a leader in the digital health transformation movement.