Configuration Specialist, TPA

Relation Insurance is a leading, innovative company with a strong commitment to excellence and a passion for delivering cutting-edge solutions to our clients. As a key player in the insurance market, we pride ourselves on our dynamic culture, collaborative environment, and continuous drive for success. With a rich history and a bright future ahead, we are looking for exceptional individuals to join our team and contribute to our ongoing growth and success.

The 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.

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.

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…