Sr. High Risk Claims Specialist

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.

High-dollar claims, dialysis cases, and stop loss files aren't routine paperwork — they're the moments when members and clients need us to get it exactly right. A missed detail or a slow turnaround on a complex claim can mean a delayed treatment, a frustrated client, or real financial exposure for the business. This role sits at that pressure point, turning complicated, high-stakes claims into accurate, compliant, on-time outcomes.

Every claim adjudicated correctly builds trust with clients and protects the people counting on their coverage to work when it counts. The sharper the review, the stronger Personify Health's reputation for getting the hard cases right.

• Adjudicate high-dollar and specialty claims: Review, analyze, and process complex healthcare, dialysis, and stop loss claims from intake through resolution, catching errors before they become problems.
• Enforce quality and compliance standards: Examine each claim against company policy and regulatory requirements, making sure every decision holds up to scrutiny.
• Own production and turnaround targets: Complete claims work within required time frames while maintaining the accuracy standards the role demands.
• Guide the claims team through escalations: Serve as the go‑to resource when teammates hit complex questions or edge cases that need deeper claims expertise.
• Validate plan setup and documentation: Review plan documents and vendor arrangements to confirm system configuration is correct before claims are processed against it.
• Flag risk before it spreads: Identify and elevate potential errors in plan documents, claims processing, or system setup so issues get fixed at the source.
• Drive the stop loss renewal process: Manage assigned stop loss renewal tasks accurately and on schedule, as directed by management.
• Stay current on the regulatory landscape: Complete required training and keep pace with evolving claims processing guidelines and industry standards.
• Deliver direct client and vendor support: Serve as a point of contact for clients, internal staff, and vendors to resolve claims questions and keep cases moving.
• Support strategic projects: Take on special assignments from supervisors and managers that strengthen the broader claims operation.

What You Bring to Our Team

Education & Experience:

• Degree in Business, Healthcare Administration, or a related field preferred; equivalent work experience considered
• 4+ years of experience in claims processing, adjudication, or related healthcare/insurance operations
• 4+ years of experience working across multiple claims processing systems
• Healthcare industry background preferred, including health insurance, medical office, billing, or clinical operations experience

Technical

Skills:

• Thorough knowledge of medical terminology and ICD-9, CPT, and HCPCS coding
• Proficiency with claims processing systems and Microsoft Office Suite
• Experience with reporting tools
• Working knowledge of insurance database systems a plus

The Highlights:

• Competitive base salary and benefits effective day one
• Comprehensive medical and dental through our own health solutions (yes, we use what we build)
• Paid Time Off—rest and recharge time is non‑negotiable
• Mental health support, retirement…