Healthcare Stop Loss Specialist

Personify Health•Tempe, AZ

About The Position

Personify Health is seeking a Healthcare Stop Loss Specialist to manage the stop loss claim filing process. This role is crucial for ensuring accurate and timely stop loss filings, which protect clients and recover financial reimbursements. The specialist will be responsible for managing specific claimants, tracking reimbursements, and maintaining alignment between carriers and internal teams. The accuracy and timeliness of this role directly impact the company's cash flow, client financial outcomes, and the integrity of Personify Health's stop loss operations.

Requirements

High school diploma or GED required.
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.
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.

Nice To Haves

Additional education in healthcare, business, or a related field a plus.

Responsibilities

Assess claim eligibility against excess loss policy terms, gather required documents, run reports, and submit spec claimant filings within established internal timeframes.
Create and manage the initial specific file for each claimant, keeping records accurate, complete, and audit-ready throughout the claim lifecycle.
Monitor all reinsurance requests to confirm receipt, generate weekly outstanding reimbursement reports, and follow up directly with stop loss carriers to drive resolution.
Keep the database of specific reimbursement requests current and accurate, ensuring leadership and teammates have reliable data to work from.
Coordinate communication between pharmacy benefit managers and internal stakeholders as it relates to stop loss claimants, keeping all parties informed and aligned.
Keep your supervisor informed of unresolved, disputed, or at-risk items in a timely manner so issues get addressed before they compound.