Performs system configuration and validation for both new and renewing clients .
Collaborates with business partners to gather and clarify requirements.
Reviews prior benefit plans and makes recommendations for new group implementations, such as system capabilities and regulatory requirements, benefit design recommendations and presents to new clients.
Configures benefits into our claims system and prepares corresponding end-user documentation for new group implementations, as needed.
Creates claim system benefit configuration revisions and prepare corresponding end-user documentation for renewing clients and implementation of off-cycle benefit changes.
Documents workflows, configuration decisions, and process updates.
Troubleshoots configuration issues and recommends solutions.
Reviews change requests for completeness and alignment with existing processes.
Provides Plan Configuration Analyst training/education and assists in developing training materials.
Communicates status updates and risks to senior analysts and Plan Configuration Manager.
Reviews and responds to applicable TechOps Support tickets and BPO claims queries as needed.
Manages the SSO tool for non-preferred PBMs.
Conducts peer-to-peer audit for claims system configuration.
In conjunction with Level III analyst, set up BlueCard requirements. This includes, but is not limited to, negotiations with CHP (Consortium Health Plans) and processing of CBF (Capitated Billing Format) payments, PAR requests, and plan prefix setup.
Work with the Finance team to conduct EOB setup auditing, as needed.
Participates in code categorization decisions and leads review of annual compliance requirements related to preventative services.
Participates in various department and company-wide projects as needed.

Requirements

High school diploma or equivalent experience required
3-5+ years of recent relevant Health Plan Configuration experience
Comprehensive understanding of benefits that we administer and different plan types.
Understanding of self‑funded plan structures, accumulators, stop‑loss, and employer‑specific plan variations.
Strong ability to analyze benefit documents (SPDs, plan summaries) and translate them into system rules.
Strong understanding of regulations that impact benefit design, including but not limited to, the Affordable Care Act, Mental Health Parity and IRS rules related to administration of high-deductible health plans.
Experience troubleshooting configuration issues and validating system outputs.
Growing familiarity with claims platforms or HRP systems used by TPAs.
Clear and effective verbal and written communication skills.
Strong interpersonal skills and ability to work with team members at all levels.
Ability to create and run SQL queries recommended.
Ability to analyze and understand medical claims adjudication logic.

Benefits

Seventeen (IC) days paid time off (individual contributors)
Eleven paid holidays
Two paid personal and one paid volunteer day
Company-subsidized medical, dental, vision, and prescription insurance
Company-paid disability, life, and AD&D insurances
Voluntary insurances
HSA and FSA pre-tax programs
401(k)-retirement plan with company match
Annual $500 wellness incentive and a $600 wellness reimbursement
Remote work and continuing education reimbursements
Discount program
Parental leave
Up to $1,000 annual charitable giving match

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Health Plan ConfigurationSQLbenefit design analysistroubleshooting configuration issuessystem validationclaims system configurationEOB setup auditingBlueCard requirements setupprocess documentationcode categorization

Soft Skills

verbal communicationwritten communicationinterpersonal skillsanalytical skillscollaborationtraining and educationproblem-solvingstatus reportingrisk communicationpeer auditing