Operations Specialist

Job Description

Job Description

POSITION SUMMARY:

The Operations Specialist manages the critical intersection of plan eligibility, continuity of coverage, and complex claims dispute resolution for our self-funded employer clients. This role is designed for a highly analytical, curious individual who doesn't just execute repetitive tasks but actively looks for ways to improve them. You will ensure 100% compliance in enrollment and COBRA administration, author high-quality appeals determinations, and leverage AI tools to automate routine data workflows, reducing turnaround times and human error.

RESPONSIBILITIES:

1. Enrollment & Eligibility Quality Control

• Automate the ingestion and validation of weekly EDI 834 enrollment files from employer clients, brokers, and ben-admin platforms.

• Investigate and resolve complex eligibility discrepancies between our core system, stop-loss carriers, and PBMs to prevent coverage gaps.

• Oversee the structural audits of system builds during new group implementation to ensure digital eligibility rules perfectly match the executed Summary Plan Description (SPD).

2. COBRA Administration & Compliance

• Oversee the automation and management of COBRA communication generation, mailing, and tracking within strict ERISA timelines.

• Manage complex employer-subsidized COBRA premium structures, severance arrangements, and retroactive reinstatements.

• Serve as the subject matter expert on COBRA regulatory shifts, ensuring our automated notifications and processes remain 100% compliant.

3. Appeals Adjudication & Writing

• Conduct objective, end-to-end reviews of first-level administrative and medical necessity appeals for self-funded plans.

• Synthesize complex medical records, plan document language, and federal guidelines to draft legally defensible, clear, and empathetic appeal determination letters.

• Coordinate with stop-loss carriers on high-dollar appeals to guarantee that overturned denials align with reinsurance contracts.

4. Workflow Automation & AI Integration

• Identify repetitive, manual tasks in your daily queue (such as comparing massive enrollment spreadsheets or drafting repetitive letters) and build automated solutions using internal AI tools, prompt engineering, or RPA/low-code tools (e.g., Power Automate, Excel Power Query).

• Proactively find ways to use LLMs to summarize dense clinical notes or cross-reference plan documents, reducing appeal review times.

• Other duties as assigned.

QUALIFICATIONS:

• 2+ years of experience in TPA operations, benefits administration, or medical claims.

• Solid understanding of ERISA, COBRA, HIPAA, and PPACA regulations, particularly regarding self-funded group health plans.

• Experience with TPA administration platforms (e.g., LuminX, Eldorado/Javelina, WLT) and advanced Microsoft Excel skills (VLOOKUP/XLOOKUP, Pivot Tables, Power Query).

• Practical experience utilizing AI tools (like ChatGPT, Claude, Gemini, or Copilot) to draft correspondence, summarize complex information, or analyze tabular data.

Key Performance Indicators (KPIs)

1. Compliance Accuracy: 100% adherence to DOL appeal timelines and COBRA notification windows.

2. Enrollment Cleanliness: Zero retroactive premium leakage due to unresolved eligibility discrepancies over 30 days old.

3. Efficiency Gain: Measurable reduction in hours spent on routine manual tasks through the deployment of AI or automation workflows.

ABOUT FIRST CHOICE HEALTH:

First Choice Health, headquartered in Seattle, WA, is a provider-owned healthcare organization offering employers a forward-thinking alternative to traditional health insurance. We have been serving employers of all sizes and across many industries with exceptional health benefits administration for over 35 years, providing unparalleled access to a growing number of clinically integrated networks (CIN) and a traditional PPO. Alongside our Employee Assistance Program (EAP) addressing mental health and work-life balance, our services collectively support members in every step of their healthcare journeys.
At First Choice Health, we are proud to deliver the personalized, quality service our clients deserve, while reducing costs and keeping their members healthy.

OUR PURPOSE, VALUES & CULTURE:
Uniting providers, employers, and individuals, we deliver sustainable solutions that elevate the health and care of our communities.

CARE  TRANSPARENT  COLLABORATE  RELENTLESS  INNOVATE  

We strive to uphold the above values and take steps to cultivate our culture through each one. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life. Learn more about how we foster a culture of belonging.

At First Choice Health, we believe that a culture that fosters  belonging- one that accept employees for who they are, nurtures creative thinking, and appreciates different perspectives drives our success. By cultivating an environment where every voice is valued, we empower our employees to bring their best selves to work, enable us to serve our clients and communities more effectively. We work as a community, guided by our values and are unified in our mission to make healthcare access easier for everyone from all walks of life. 

BENEFITS: