Claims and Enrollments Specialist at Human Resource Concepts LLC

We are seeking a detail-oriented and motivated Enrollment and Claims Specialist to join our team. In this role, you will be a key player in our third-party administrator (TPA) services, responsible for the accurate and timely processing of participant enrollments and claims for various benefit accounts. You will manage the electronic data interchange (EDI) and claims files that are central to our operations, ensuring data integrity and seamless benefit administration for our clients.

• Manage the end-to-end process of participant enrollments for various benefit plans, including Flexible Spending Accounts (FSA), Dependent Care Accounts (DCA), Health Reimbursement Arrangements (HRA), and Health Savings Accounts (HSA). This includes accurately entering and updating information in our CRM systems (e.g., Monday.com, WEX, or other CRM systems).

• Proactively communicate with clients, points of contact (POCs), and brokers to resolve any enrollment discrepancies or missing information.

• Collaborate with internal departments to research and resolve complex enrollment issues, ensuring a positive participant experience.

• Process a variety of participant claims for benefit plans such as Flexible Spending Accounts (FSA) and Dependent Care Accounts (DCA), ensuring a high degree of accuracy and efficiency.

• Conduct thorough research on claims, communicating with participants and other departments to gather all necessary documentation for processing.

• Handle claim adjustments and ensure all processing complies with plan provisions and regulatory requirements.

• Take ownership of importing and exporting various data files, including .txt, .csv, and other file types related to enrollments and claims.

• Manage and process standard healthcare EDI files, such as EDI 834 (Benefit Enrollment and Maintenance), EDI 837 (Healthcare Claim), and EDI 835 (Healthcare Claim Payment/Remittance Advice).

• Perform data quality checks on all incoming and outgoing files to maintain the integrity of our systems, ensuring compliance with HIPAA and other regulatory standards.

• Troubleshoot and resolve any EDI file processing errors, and work with trading partners to ensure the smooth transmission of data.

• Reconcile processed claims against remittance advice to ensure accurate payment posting and identify any discrepancies.

• Previous experience in enrollments and claims processing is highly preferred.

• Experience working for a third-party administrator (TPA), insurance carrier, or in a benefits administration role is a plus.

• Demonstrated experience with office productivity suites like Google Workspace and Microsoft Office.

• High level of proficiency in Microsoft Excel, including the ability to perform V-lookups and manage large datasets.

• Familiarity with text editors such as Notepad++ for handling data files is a plus.

• Exceptional attention to detail and a commitment to accuracy.

• Strong analytical and problem-solving skills, with the ability to research and resolve complex enrollment and claim issues.

• Excellent communication and interpersonal skills, with a customer-service orientation.

• Proficient computer skills and the ability to quickly learn new software and systems.

• Proven ability to work independently and as part of a team in a fast-paced environment.