Claims & Compliance Systems Specialist

Job Description

Job Description

Claims & Compliance Systems Specialist

Department: TPA Division

Reports To: TPA Division Manager

FLSA Status: Non-Exempt

Employment Status: Full-Time, Monday–Friday, 8:30am–5:00pm, Hybrid after 90 Days

Salary: $70,000-$80,000 annually, based on experience

About Us

Bene-Care is a family-built, service-driven partner in workforce solutions and full-service insurance. Based in Rochester, NY, we've helped businesses thrive through custom strategies across employee benefits, payroll, HR, property & casualty insurance, and TPA services. We take a consultive, service-first approach to every client relationship and pride ourselves on innovation, accountability, and long-term growth.

Position Summary

The Claims & Compliance Systems Specialist performs the full range of claims processing and compliance functions within Bene-Care's Third-Party Administration division, with a deeper focus on leveraging technology and systems to support TPA operations. This role is best suited for a detail-oriented professional with the technical aptitude to navigate complex platforms, troubleshoot issues, and work confidently with data-driven processes. This is a hands-on role for a self-starter who thrives in the details of benefit administration systems, takes ownership of problems, and finds satisfaction in figuring things out. As part of this role, the specialist will develop working knowledge of TPA plan types and benefit structures, applying that understanding across daily claims and compliance functions.

Essential Duties and Responsibilities :

• Develop working knowledge of the Summit TPA system, including plan setups, enrollment configurations, claims workflows, and system troubleshooting.
• Stay current on Summit system updates, enhancements, and bug fixes.
• Import and validate enrollment files for new groups and at renewal; identify and resolve data discrepancies.
• Review and audit benefit plan configurations in Summit following setup by the TPA Operations Manager to ensure accuracy before go-live.
• Perform weekly imports of insurance carrier claim files for claim crossover processing.
• Maintain a master tracking file of insurance carrier claim data, updating weekly upon receipt of carrier claim files.
• Handle weekly payment processing of claim reimbursements.
• Serve as the primary point of contact for assigned groups, including reviewing benefit card transactions and responding to related inquiries.
• Key and review claim submissions for weekly reimbursement processing
• Conduct audits of claims data; identify patterns, errors, or irregularities and recommend corrective action.
• Support employees and clients with plan and claims inquiries, including assistance with online accounts and mobile apps, troubleshooting issues, and escalating when necessary.
• Maintain detailed and accurate records of all claims activities, correspondence, and status updates.
• Ensure all claims processing and documentation adheres to applicable federal and state regulations, including ERISA, ACA, HIPAA, and IRS guidelines.
• Complete Non-Discrimination Testing for applicable TPA plans; distribute results to groups and advise on corrective steps for plan failures.
• Configure and run PCORI reports within the system, distribute to applicable groups, and respond to related client inquiries.
• Generate compliance documents (plan documents, amendments, and required notices) and Summary of Benefits and Coverage (SBCs) for new groups and renewals.
• Provide ongoing operational support to the Benefits Sales team, including responding to group questions, generating reports, and assisting with client-facing materials.
• Prepare open enrollment materials and attend and/or schedule open enrollment meetings for groups and employees.
• Conduct training sessions on TPA systems and processes for group HR contacts and employees.
• Identify opportunities for process improvements and implement solutions to enhance efficiency and accuracy.
• Perform other work-related duties as assigned.

Minimum Qualifications (Knowledge, Skills, and Abilities):

• Bachelor's degree in business administration or a related field preferred
• A natural curiosity for technology and systems, with the technical aptitude and initiative to learn quickly, troubleshoot issues, and proactively work through problems.
• Strong analytical and problem-solving skills with a process-improvement mindset.
• Proficiency in Microsoft Office Suite.
• Exceptional customer service skills with strong written and verbal communication abilities; able to build rapport and communicate effectively with clients and employees.
• Strong attention to detail and ability to manage multiple deadlines and a fluctuating workload in a fast-paced environment.
• Previous experience working within a benefits administration system, including data file imports and carrier files, is highly desirable.
• Knowledge of applicable regulations and industry best practices, including ERISA, ACA, HIPAA, and IRS guidelines.

Note: Should any licensing or certification become required, Bene-Care will cover the cost of any associated coursework and exams.

Physical Demands and Work Conditions:

The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodation. While performing the duties of this position, the employee is frequently required to sit, walk, bend, use hands (i.e.: type, write), talk, and hear. The employee is occasionally required to stand and walk. Employee may occasionally be required to lift and/or move up to 25 pounds. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate.

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Nothing in this document should be interpreted as an offer of employment and all employment with Bene-Care and its affiliates is at-will. Reasonable accommodations will be made as determined by the interactive process upon request and job duties may be adjusted as needed to ensure that any current or potential employee is successful at Bene-Care. Bene-Care and its affiliates are Equal Opportunity Employers.