Configuration Specialist, TPA

Summary

Relation Insurance Services is an insurance services company seeking a Configuration Specialist, TPA. The role configures and maintains health benefit plans in a third-party administrator claims system, validates configurations through testing, supports accurate claims adjudication, and resolves configuration issues.

Responsibilities

• 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

Skills

• High school diploma or equivalent required
• Minimum two years of experience in health benefit administration, medical claims processing, plan configuration, or a related healthcare benefits function
• 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
• Two or four-year degree in business, healthcare administration, information systems, or a related field preferred
• 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

Qualifications

Must Haves

• High school diploma or equivalent required
• Minimum two years of experience in health benefit administration, medical claims processing, plan configuration, or a related healthcare benefits function
• 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

Nice to Haves

• Two or four-year degree in business, healthcare administration, information systems, or a related field preferred
• 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

Benefits

• Family health and wellness programs
• 401K
• Employee assistance programs
• Paid time off
• Paid holidays
• Career advancement and development opportunities
• Eligibility 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 individual and organizational performance