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Yuzu is a tech-enabled Third Party Administrator (TPA) powering innovative health plans centered on care navigation, capitated primary care, and real-time payments. The Claims Integrity Specialist manages member and provider appeals, coordinates stop loss submissions, and ensures accuracy, fairness, and regulatory compliance across all determinations.
Primary responsibilities include leading intake, investigation, and resolution of member and provider appeals; analyzing documentation, medical records, and coding to make accurate determinations; drafting compliant appeal decision letters; and ensuring adherence to ERISA, ACA, and state regulations. The role participates in internal and external audits, maintains thorough documentation, and identifies trends to recommend process improvements.
Secondary duties involve preparing and submitting stop loss claims, reviewing claims data for eligibility and accuracy, tracking reimbursements, monitoring high-cost claimants, and maintaining tracking logs. The specialist reviews stop loss policies for compliance and ensures all documentation meets audit standards.
Ideal candidates have 3–5 years of experience in medical claims, appeals, stop loss, or healthcare administration (TPA experience preferred). Required knowledge includes medical billing rules, CPT/HCPCS coding, ICD-10, ERISA, ACA, and state-specific regulations. Strong analytical skills, attention to detail, ability to interpret complex plan documents, and excellent written/verbal communication are essential.
Yuzu offers equity opportunities, competitive salary, health benefits, 401(k) matching, career development, and a remote-friendly, high-trust environment with transparency and autonomy.
