Job Details

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.

• 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.

• 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.

• 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.

• 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.

• 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.