Claims Integrity Specialist

About the Role

The Claims Integrity Specialist is responsible for managing member and provider appeals and coordinating stop loss submissions. This role ensures the accuracy, fairness, and compliance of all determinations while partnering closely with internal teams and external stakeholders. The ideal candidate possesses strong analytical skills, exceptional attention to detail, and a commitment to integrity in every decision.

Primary Key Responsibilities

• Appeals & Disputes: Lead the intake, investigation, and resolution of member and provider appeals. Analyze documentation, medical records, coding, and benefit language to make accurate, well-supported determinations. Draft clear, compliant, and timely appeal decision letters and responses. Collaborate with the claims team and other internal stakeholders as needed. Ensure all appeal decisions comply with ERISA, ACA, state regulations, and internal policies. Participate in internal and external audits, including stop loss, client, and regulatory audits. Maintain thorough, accurate documentation for audit readiness and quality review. Identify trends or patterns in appeals or provider behavior and recommend policy or process enhancements.
• Secondary Stop Loss Claims Filings: Prepare, compile, and submit initial and ongoing stop loss claims in accordance with each carrier's requirements. Review claims data to validate eligibility, plan benefits, accumulators, billing accuracy, and patient responsibility prior to submission. Track reimbursements, reconcile payments, and ensure recoveries align with expectations. Maintain timely communication with stop loss carriers to resolve outstanding items or documentation requests.
• High-Cost Claimant Oversight: Identify potential stop loss claimants through daily and weekly high-dollar claim reporting. Monitor claims approaching the specific deductible and ensure accurate accumulation. Maintain updated logs for tracking submission statuses and required follow-ups.
• Policy & Contract Administration: Review stop loss policies to ensure compliance with contract terms, exclusions, filing deadlines, and reimbursement provisions.
• Data Integrity & Reporting: Maintain and update tracking logs summarizing appeals outcomes, stop loss submissions, and reimbursement statuses. Ensure all documentation meets audit and compliance standards.

Who We're Looking For

We're seeking a motivated, ethical, and compassionate professional who thrives in a detail-oriented, fast-paced environment and is dedicated to delivering fair, accurate outcomes. If you are passionate about doing the right thing and bringing integrity to every claim, you'll be a strong fit for this role.

Qualifications

• 3–5 years of experience in medical claims, appeals, stop loss, cost containment, or related healthcare administration roles (TPA experience preferred)
• Strong knowledge of medical billing rules, CPT/HCPCS coding, ICD-10, and reimbursement methodologies
• Excellent understanding of ERISA, ACA, and state-specific claims regulations
• Strong analytical and problem-solving skills with impeccable attention to detail
• Ability to interpret complex plan documents and apply benefits accurately
• Strong written and verbal communication skills, including drafting compliant appeal determinations

Benefits

• Equity opportunities
• Competitive salary
• Health benefits
• 401(k) with employer matching
• Career growth and development opportunities
• Remote-friendly environment
• A high-trust team with radically high transparency and autonomy

Our Interview Process

• A 30–45 minute video conversation with Claims Operations Leadership
• A follow-up conversation with members of the broader Operations Leadership team
• A take-home assignment (~2 hours) reflecting real, on-the-job scenarios
• Reference checks from 1–2 individuals of your choosing
• A possible onsite visit to our NYC office, depending on your location and role expectations