Benefit Operations Specialist

Remote (United States)

About the Role

This opportunity is for a Benefit Operations Specialist who will support the delivery of integrated medical and pharmacy benefit programs. The role focuses on benefit configuration, claims testing, quality assurance, implementation support, and ongoing troubleshooting to help ensure benefit plans are accurate, compliant, and aligned with client requirements.

Status: Full Time

Hourly Pay: Approximately $36.06 - $43.27 per hour

What You’ll Do

• Manage all aspects of benefit configuration, including new plan setup, plan changes, claims testing, and recurring audits.
• Work cross-functionally with product, development, client services, and other stakeholder teams to support customized benefit requests for new plans and plan changes.
• Clearly explain benefit configuration setup, testing processes, and specific test claims to clients in a way that is easy to understand.
• Recommend improvements to workflows and systems that affect plan and benefit design, with a focus on efficiency and quality.
• Support the creation of new benefit options that align with market needs, including expansion into government programs.
• Develop standard and custom batch testing scenarios and inputs, then review test claim outputs to validate claim accuracy against client benefit designs.
• Create standard policies, procedures, training materials, and educational resources for cross-functional teams.
• Maintain appropriate quality standards and meet production SLA response times.
• Participate in client meetings to review new client benefit information, assess change requests, and confirm that benefit logic supports the intended configuration.
• Partner with leadership to develop benefit plan designs that meet client needs, health plan business requirements, and applicable regulatory or oversight requirements.
• Partner with Client Services during client go-live processes and help troubleshoot benefit-related discrepancies, errors, and issues.
• Support general business and team needs as assigned.
• Follow the applicable code of conduct, including reporting any noncompliance concerns when required.

Qualifications

• Bachelor’s degree preferred.
• 5+ years of TPA or health plan experience in medical benefit configuration, benefit testing, claims monitoring, SPD creation, medical coding, or a related operational area.
• 3+ years of experience with Cigna is a plus.
• Experience with pharmacy, dental, or vision benefits is a plus.
• Experience with self-funded plans, Medicare or government programs, and ERISA is preferred.
• Strong attention to detail with the ability to shift priorities quickly in a fast-paced, deadline-driven environment.
• Excellent written and verbal communication skills.
• Experience working with product and development teams is preferred.
• Familiarity with Agile processes is preferred.
• Experience working with structured or unstructured data in Excel, SQL, or data visualization tools is preferred.
• IFEBP certification is a plus.