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Senior High Risk Claims Specialist
Personify Health. Review, analyze, and process complex healthcare, dialysis, and stop loss claims from intake through resolution .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in claims processing and adjudication within the healthcare industry, with a strong understanding of medical terminology and coding systems such as ICD-9, CPT, and HCPCS. Proficient in managing complex claims while ensuring compliance with regulatory requirements and maintaining accuracy.
Highest-signal resume keywords
Claims ProcessingICD-9, CPT, HCPCS CodingHealthcare Industry ExperienceClaims AdjudicationMicrosoft Office Suite Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ProcessingICD-9 CodingCPT CodingHCPCS CodingClaims AdjudicationReporting ToolsInsurance Database SystemsRegulatory ComplianceHealthcare TerminologyClaims Resolution
Soft Skills
Problem SolvingCommunicationCollaborationAttention to DetailTime Management
Tools & Technologies
Claims Processing SystemsMicrosoft Office SuiteReporting Tools
Industry Keywords
HealthcareHealth InsuranceDialysis ClaimsStop Loss ClaimsMedical Office OperationsBillingClinical Operations
About the role
Key responsibilities & impact- Review, analyze, and process complex healthcare, dialysis, and stop loss claims from intake through resolution
- Examine claims against company policy and regulatory requirements
- Complete claims work within required timeframes while maintaining accuracy
- Serve as a go-to resource for complex questions and escalations
- Review plan documents and vendor arrangements to validate system configuration
- Identify and escalate potential errors in plan documents, claims processing, or system setup
- Manage assigned stop loss renewal tasks accurately and on schedule
- Complete required training and stay current on regulatory and industry standards
- Support clients, internal staff, and vendors with claims questions
- Resolve claims questions and keep cases moving
- Take on special assignments that strengthen the broader claims operation
Requirements
What you’ll need- 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
- 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
- Ability to complete required training and keep pace with evolving claims processing guidelines and industry standards
Benefits
Comp & perks- Competitive base salary
- Comprehensive medical and dental through our own health solutions
- Paid Time Off
- Mental health support
- Retirement planning
- Financial protection
- Professional development with clear career progression and learning budgets
- Wellness programs
- Other employee perks
- Full benefits package effective day one