[Hiring] Sr Claims Escalations Specialist @Personify Health

Role Description

Ready to turn claims chaos into resolved outcomes for Northwell members?

Every escalated claim represents a member or client waiting for an answer, and how fast and accurately that answer comes together directly shapes trust in the organization. This role sits at the center of the West Region's claims operation, catching errors before they become bigger problems and turning complex, high-stakes cases into resolved outcomes. The work goes beyond processing—it's about protecting compliance, safeguarding client relationships, and making sure the system actually works the way it's supposed to for the people relying on it. When issues repeat, this role digs into the root cause and pushes for real process fixes instead of quick patches. Getting this right, claim after claim, is what keeps Northwell's trust in this team intact.

What You'll Actually Do:

• Own escalated claims resolution: Take ownership of customer-initiated claim escalations, inquiries, and disputes from first contact through final resolution, keeping client and member satisfaction at the center of every decision.
• Drive accurate claims processing: Review, analyze, and process healthcare claims and adjustments across multiple systems, ensuring every claim meets company policy and regulatory standards before it's finalized.
• Investigate root causes: Dig into recurring claims issues, identify the underlying trends, and partner with internal teams to fix the source of the problem rather than the symptom.
• Validate plan and system setup: Review plan documents and vendor details to confirm claims are configured correctly in the system, flagging setup errors or plan document issues to management before they cause downstream problems.
• Manage stop loss renewals: Handle the stop loss renewal process as directed by management, ensuring accuracy and timeliness throughout.
• Recommend process improvements: Translate patterns in claims issues into concrete recommendations that improve service delivery and processing efficiency.
• Hit production and quality targets: Complete claims tasks within required timeframes while maintaining the quality and procedural standards that keep the operation compliant.
• Coordinate across teams: Serve as the connection point between clients, internal staff, and vendors to keep escalations moving and satisfaction high.
• Support leadership initiatives: Step in on special projects and management requests, bringing claims expertise to broader operational priorities.
• Complete required training: Stay current on all training requirements to keep pace with evolving policies, systems, and regulatory standards.

Qualifications

• High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration or related field preferred.
• Minimum of 3 years of experience in healthcare claims examination or adjudication.
• Healthcare industry background, including health insurance, medical office, clinical, billing, or admissions experience.
• Strong knowledge of medical terminology, CPT/ICD-10 coding, and healthcare billing procedures.
• Experience across multiple claims processing platforms; Anthem processing experience a plus.
• Experience with both manual and automated claims processing.
• Proficiency in Windows and Microsoft Office, including Word, Outlook, and Excel.
• Familiarity with insurance database systems a plus.

Benefits

• 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.

This position offers a base salary range of $22-$25 per hour, depending on location, skills, and experience. You're eligible for our full benefits package starting day one.

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.

Personify Health will never ask for payment or sensitive personal information like social security numbers during hiring. All official communication comes from verified company email addresses and or our secure applicant tracking system. Suspicious requests? Report them to [email protected] . View all legitimate openings at personifyhealth.com/careers .