Job Summary  

The Claims Examiner is responsible for reviewing, processing, and adjudicating complex employee benefit claims with accuracy, timeliness, and regulatory compliance. This role requires deep experience within Third-Party Administration (TPA) environments and a strong understanding of benefits administration, plan provisions, claims regulations, and client-specific requirements. The ideal candidate is detail-oriented, analytical, customer-focused, and capable of independently managing high-volume claims while maintaining exceptional quality standards.

Primary Responsibilities 
Claims Processing & Adjudication

• Review, analyze, and adjudicate medical, dental, vision, disability, FSA/HSA, and/or other employee benefit claims in accordance with plan documents, federal and state regulations, and internal policies.
• Validate claim eligibility, coverage levels, coding accuracy, and required documentation.
• Apply plan provisions, benefit rules, and adjudication guidelines to determine appropriate payment or denial outcomes.
• Identify discrepancies, incomplete information, or potential errors, and follow up for clarification or additional documentation as needed.
• Ensure all claim decisions are documented thoroughly and clearly in the claims management system.

Quality, Compliance & Regulatory Adherence

• Maintain strict adherence to ERISA, HIPAA, and other relevant regulatory requirements.
• Follow established internal controls, confidentiality requirements, and audit procedures.
• Participate in quality review processes and implement feedback to improve accuracy and consistency.
• Escalate potential compliance risks, fraud indicators, or unusual claim patterns.

Client & Member Support

• Provide clear and professional communication to members, clients, and providers regarding claim determinations, plan benefits, and required documentation.
• Collaborate with client services, benefits administration, and eligibility teams to resolve discrepancies or complex claim issues.
• Support client-specific plan setup, updates, and testing as needed.

TPA & Benefits Administration Expertise

• Interpret and administer multiple benefit plans, each with unique rules, eligibility structures, and funding arrangements.
• Utilize TPA systems and tools to research claims history, eligibility data, and prior approvals.
• Assist in onboarding new plans by validating claims configurations and benefit rule setup.

Operational Support & Continuous Improvement

• Meet or exceed performance metrics, including accuracy, productivity, turnaround time, and service quality.
• Identify opportunities to improve claims workflows, documentation, and system processes.
• Participate in team meetings, training sessions, and cross-functional initiatives.

  
Education and Experience 

• 3-5+ years of claims adjudication experience within a TPA or benefits administration environment.
• Strong knowledge of employee benefit plans, including medical, dental, vision, disability, FSA/HSA, and/or other employer-sponsored benefits.
• Hands-on experience interpreting Summary Plan Descriptions (SPDs), plan rules, and regulatory guidelines.
• Familiarity with ICD, CPT, HCPCS, and other medical coding standards (if medical claims related).
• Excellent analytical and problem-solving skills with high attention to detail.
• Strong written and verbal communication skills.
• Ability to manage multiple priorities in a fast-paced environment while maintaining accuracy.
• Experience with major TPA platforms (e.g., WEX, UMR, HealthEquity, Client, DataPath) or similar claims systems.
• Knowledge of COBRA, ACA, HIPAA, ERISA, and state-mandated benefit regulations.
• Prior experience supporting employer groups or multi-plan environments.
• Industry certifications (e.g., CEBS, FMLA/ADA certification, coding certifications) a plus.
  

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