Sr. High Risk Claims Specialist

Sr. High Risk Claims Specialist

Personify Health

Ready to bring precision and speed to the claims that matter most?

Why This Role Matters

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.

What You'll Actually Do

• 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 timeframes 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 escalate 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

Benefits

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 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

• Want the full picture? Visit personifyhealthbenefits.com to explore our complete benefits package, wellness programs, and other employee perks.

• Compensation: This position offers a base salary range of $22.00-$25.00 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

• 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.

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