Stop Loss Specialist

Overview

Who We Are

Because health is personal. That's why Personify Health created the first and only personalized health platform—bringing health plan administration, holistic wellbeing solutions, and comprehensive care navigation together in one place. We serve employers, health plans, and health systems with data-driven solutions that reduce costs while actually improving health outcomes. Together, our team is on a mission to empower people to lead healthier lives.

Learn even more about the work that drives us at personifyhealth.com.

Responsibilities

Ready To Own Stop Loss Submissions, Reconciliations, and Reimbursement Tracking From Filing Through Receipt?

Why This Role Matters

Stop loss reimbursement is only as reliable as the process behind it. This role tracks, submits, and monitors stop loss claims end-to-end — ensuring carriers receive what they need on time, reimbursements are posted accurately, and nothing falls through the cracks. It requires a working command of stop loss contracts, plan documents, and the claims cycle that underpins self-funded plan administration.

What You'll Actually Do

File and process spec claimant submissions: Run reports, gather required documentation, and manage email correspondence to submit spec claimants within established internal timeframes.

Respond to carrier requests: Research and address carrier requests for additional claims information accurately and on time.

Reconcile and post reimbursements: Perform monthly group reconciliations, track incoming reimbursements from carriers, and post funds accurately to the appropriate accounts.

Generate stop loss reports: Prepare monthly stop loss reports — including RX — and produce weekly outstanding reimbursement reports for carrier follow-up.

Submit and track appeals: File appeals to stop loss carriers as needed and monitor outcomes through resolution.

Send weekly innovative notices: Review and distribute weekly notices to carriers in accordance with contract requirements.

Review stop loss contracts: Read and apply the terms of individual stop loss contracts, reinsurance agreements, and Summary Plan Descriptions to guide processing decisions.

Qualifications

What You Bring to Our Team

Education & Experience

• High school diploma or equivalent required
• Prior experience in a healthcare-related field a plus
• Experience in a claims, call center, or health insurance environment a plus
• Experience with self-funded plan administration a plus
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes a plus

Technical Skills

• Proficiency in Microsoft Word, Excel, and Outlook
• Claims processing experience or medical background a plus

Our Commitment: Personify Health is an equal opportunity employer committed to diversity, equity, inclusion, and belonging. We cultivate a work environment where differences are celebrated, and employees of all backgrounds are empowered to thrive—because diversity is core to who we are and critical to our work in health and wellbeing.

Stay Safe: Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to talent@personifyhealth.com. View all legitimate openings at personifyhealth.com/careers.