Claims Review Specialist

TL;DR

Claims Review Specialist (Health Insurance): Coordinate and file Stop Loss claims, Advance Funding requests, and Plan Year End Closeouts with an accent on financial protection, eligibility determination, and compliance tracking. Focus on analyzing claims documents, managing documentation systems, liaising with carriers and clients, and generating reimbursement reports.

Location: Tempe, AZ - all candidates must be able to commute into this location weekly

Compensation: $20.00 - $30.00/hour, depending on location, skills, and experience

Company

Personalized health platform combining health plan administration, wellbeing solutions, and care navigation to reduce costs and improve outcomes for employers, health plans, and systems.

What you will do

• Prepare Stop Loss submissions by analyzing claims and documents for eligibility under Excess Loss Policy within established timeframes.
• Coordinate Advanced Funding Requests with clients and carriers while maintaining a database of reimbursement requests.
• Manage documentation by creating Specific Files for claimants and filing in EDOCS platform, including release of held claims.
• Serve as liaison between PBMs, internal clients, and Stop Loss carriers for claimants.
• Monitor reinsurance requests, generate weekly outstanding reimbursement reports, and follow up with carriers.
• Support Plan Year End Closeouts and keep supervisor informed of open or disputed items.

Requirements

• High school diploma or GED required
• Minimum 3 years related experience or equivalent
• Knowledge of medical terminology, CPT, HCPCS, and ICD-10 codes
• Proficiency in Windows and Microsoft Office (Word, Excel, Outlook)
• Detail-oriented, analytical approach with ability to handle financial reports and math concepts
• Strong communication, organization, multitasking, and problem-solving skills
• Completion of HIPAA, ICA, or LOMA training preferred

Culture & Benefits

• Competitive base salary and full benefits package starting day one, including medical and dental through our own solutions
• Unlimited PTO, mental health support, retirement planning, and financial protection
• Professional development with career progression, learning budgets, and mission-driven culture valuing diversity