Claims Integrity Specialist

🔥 0 minutes ago

🗽 New York – Remote

🗽 New York – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 12%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Yuzu

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2022

🏥 Healthcare

🛡️ Insurance

☁️ SaaS

Healthcare • Insurance • SaaS

Yuzu is a technology platform that lets organizations design, launch, and operate custom health plans and modernize third-party administrator (TPA) workflows. It provides a Benefits Builder to configure tiers, accumulators, and benefits; integrations with PBMs, stop-loss carriers, and other vendors; automated document generation and e-signature; web-based portals for employers, members, and vendors; in-house claims adjudication and payment infrastructure with real-time auto-ledgering; and reporting and support tools. Yuzu emphasizes white-labeling so customers can present fully branded plans and handles end-to-end plan operations from onboarding to live plan management.

📋 Description

• 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 • Ensure 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 documentation for audit readiness and quality review • Identify trends or patterns in appeals or provider behavior and recommend policy or process enhancements • Prepare, compile, and submit initial and ongoing stop loss claims according to carrier requirements • Review claims data to validate eligibility, plan benefits, accumulators, billing accuracy, and patient responsibility • Track reimbursements, reconcile payments, and ensure recoveries align with expectations • Communicate with stop loss carriers to resolve outstanding items or documentation requests • 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 tracking submission statuses and required follow-ups • Review stop loss policies for compliance with contract terms, exclusions, filing deadlines, and reimbursement provisions • Maintain and update tracking logs summarizing appeal outcomes, stop loss submissions, and reimbursement statuses • Ensure documentation meets audit and compliance standards

🎯 Requirements

• 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 • Possible onsite visit to the NYC office, depending on your location and role expectations