WHAT WE'RE LOOKING FORThe Configuration Specialist configures and maintains health benefit plans within Relation's Third-Party Administrator (TPA) claims administration system based on approved plan documents, benefit summaries, and client requirements. The individual in this position validates plan configurations through testing, supports accurate claims adjudication, maintains configurations for plan changes, and resolves configuration issues that affect claims processing.
A GLIMPSE INTO YOUR DAY- Configures health benefit plans in the claims administration system using approved plan documents, benefit summaries, and client requirements.
- Builds deductibles, out-of-pocket maximums, copays, coinsurance, benefit limits, exclusions, and other benefit provisions within the claims system.
- Configures applicable networks, fee schedules, reimbursement arrangements, benefit codes, system rules, and related plan components necessary to support accurate claims adjudication.
- Maintains existing plan configurations for renewals, amendments, and effective-date changes.
- Reviews plan documents and supporting materials to identify missing, conflicting, or unclear benefit information before configuration.
- Validates configured benefits against approved plan documents and client requirements.
- Develops and executes claim test scenarios to verify benefit calculations and claims processing.
- Researches configuration discrepancies identified during testing or claims processing.
- Coordinates quality assurance and testing activities with applicable team members to validate plan configurations before implementation or release.
- Coordinates plan setup and processing questions with Claims, Eligibility, Client Services, and other applicable internal teams.
- Researches and resolves configuration discrepancies identified during testing or claims processing and corrects configurations to align system processing with approved benefit provisions.
- Documents configuration changes, source materials, and testing results in accordance with established plan-build procedures.
- Identifies recurring configuration issues, root causes, and opportunities to improve plan-build accuracy, testing, and related processes.
- Uses available technology, automation tools, and Relation's proprietary AI-enabled solutions to improve configuration accuracy, testing, documentation, and workflow efficiency while appropriately protecting confidential information.
- Performs other projects, duties, and tasks, as assigned.
WHAT SUCCESS LOOKS LIKE IN THIS ROLE- High school diploma or equivalent required. Two or four-year degree in business, healthcare administration, information systems, or a related field preferred.
- Minimum two years of experience in health benefit administration, medical claims processing, plan configuration, or a related healthcare benefits function.
- Experience configuring health benefit plans within a third-party administrator (TPA), self-funded health plan, payer or health plan environment preferred.
- Familiarity with healthcare coding, HIPAA-related claims standards, or other system rules used in medical claims adjudication preferred.
- Knowledge of health plan benefit structures, including deductibles, out-of-pocket maximums, copays, coinsurance, limits, and exclusions.
- Ability to interpret plan documents, benefit summaries, and client requirements and translate the information into accurate system configurations.
- Ability to develop and execute benefit configuration testing and analyze claim processing results.
- Strong analytical and problem-solving skills and attention to detail with the ability to identify and resolve configuration discrepancies.
- Ability to document configuration changes, testing results, and issue resolution clearly and consistently.
- Proficiency in Microsoft Office and the ability to learn and effectively use claims administration, benefit configuration, and related business systems.
- Ability to manage multiple priorities and communicate effectively with operational and technical partners.
WHY CHOOSE RELATION?- Competitive pay.
- A safe and healthy work environment provided by our robust benefit program including family health and wellness programs, 401K, employee assistance programs, paid time off, paid holidays and more.
- Career advancement and development opportunities.
Note: The above is not all encompassing of the full position description.
The wage range for this role takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At Relation, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is presented within this posting.
You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, whereby an award, if any, depends on various factors, including, without limitation, individual and organizational performance.
$62,000.00 - $107,000.00
