Claims Integrity Specialist

Who We Are Yuzu is a tech-enabled, vertically integrated Third Party Administrator (TPA) powering innovative health plans centered on care navigation, capitated primary care, and real-time payments. Unlike traditional TPAs, we partner closely with plan designers who serve as care navigators, contract negotiators, and sales teams for the uniquely tailored plans they create. We currently support thousands of employees and differentiate ourselves by bringing new models of healthcare delivery to life — enabling novel ways to access and pay for care through modern, flexible health plan design. Our mission is simple: make it easy for any business to build and manage a custom health plan. We do this by efficiently processing claims, ensuring regulatory compliance, and building technology that enables custom payment flows and seamless collaboration across stakeholders. Equally important, we provide our members with compassionate, high-quality support to guide them through every step of their healthcare journey. As we continue to grow, we’re excited to welcome another talented member of the Claims team to help us maintain our standard of exceptional service and innovation. 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. Key Responsibilities Primary: 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. Ideal Candidates Will Have 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. Why Join Us 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 If selected for an interview, you can expect: 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