Contracting Specialist Benefits and Claims

Benefits and Claims

Responsibilities

• Oversee Third-Party Administrator (TPA) performance, ensuring accuracy, timeliness, and adherence to service-level agreements.
• Lead audits and compliance reviews to ensure alignment with federal and state regulations, contractual obligations, and organizational standards.
• Manage and resolve escalated claims and benefit issues, ensuring timely and effective outcomes.
• Oversee distribution, tracking, and validation of provider contracts to ensure accuracy and compliance.
• Interpret and operationalize Oregon Health Authority (OHA) and Umpqua Health Network (UHN) contractual requirements.
• Ensure accurate configuration and maintenance of benefits, fee schedules, and authorization rules within claims systems.
• Direct data integrity efforts across TPA and internal systems, ensuring consistent application of business rules.
• Provide leadership in the resolution of complex claims issues, disputes, and exceptions.
• Ensure accurate interpretation and application of benefit structures by the TPA.
• Serve as a key escalation point for internal teams and external partners.
• Develop and implement policies and procedures to strengthen claims oversight and benefit administration.
• Identify operational gaps and lead process improvement initiatives to enhance efficiency, accuracy, and compliance.
• Serve as the primary liaison for TPA-related performance and escalation matters.
• Deliver regular reporting, insights, and strategic recommendations to leadership.

Qualifications

• Bachelor’s degree in healthcare administration, Business, or a related field required
• Minimum of 5 years of experience in health plan claims processing and benefit administration, preferably with TPA oversight responsibilities
• Strong understanding of managed care operations and regulatory compliance
• Proficiency in claims systems and Microsoft Office Suite
• Strong analytical and problem-solving skills
• Excellent verbal and written communication skills, including negotiation abilities
• Ability to manage vendor relationships and enforce accountability
• Ability to analyze and interpret data to determine appropriate configuration changes
• Ability to accurately interpret state and/or federal benefits, contracts, and additional business requirements and translate them into configuration parameters
• Ability to coordinate and facilitate coding updates related to benefit plans, provider contracts, fee schedules, and system tables through the user interface
• Ability to apply previous experience and knowledge to research and resolve claim and encounter issues, including pended claims, and communicate system update needs to TPAs
• Ability to manage fluctuating workloads and prioritize tasks to meet deadlines and the needs of the user community
• Demonstrated accountability, integrity, innovation, and collaboration in a professional setting
• Certified Coder (preferred)
• Bilingual translation or translation capabilities a plus

Employment Type

Full-Time, Exempt

Work Hours

Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.

Salary

Salary is dependent on skills, experience, and education

Benefits

• Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave
• Medical, dental, and vision insurance
• 401(k) with company match (fully vested immediately)
• Company-sponsored life insurance and additional benefits
• Fitness reimbursement program
• Tuition reimbursement and more

Additional Information

Position Purpose: The Benefit and Claims Oversight Specialist is responsible for ensuring accurate, timely, and compliant administration of health plan benefits and claims through Umpqua Health’s Third-Party Administrator (TPA).

Challenges: Working with a variety of personalities, maintaining a consistent and fair communication styles, satisfying the needs of a fast-paced and challenging company.

Minimum Qualifications: Bachelor’s degree in healthcare administration, Business, or a related field required; minimum of 5 years of experience in health plan claims processing and benefit administration, preferably with TPA oversight responsibilities; strong understanding of managed care operations and regulatory compliance; proficiency in claims systems and Microsoft Office Suite; strong analytical and problem-solving skills; excellent verbal and written communication skills, including negotiation abilities; ability to manage vendor relationships and enforce accountability; ability to analyze and interpret data to determine appropriate configuration changes; ability to accurately interpret state and/or federal benefits, contracts, and additional business requirements and translate them into configuration parameters; ability to coordinate and facilitate coding updates related to benefit plans, provider contracts, fee schedules, and system tables through the user interface; ability to apply previous experience and knowledge to research and resolve claim and encounter issues, including pended claims, and communicate system update needs to TPAs; ability to manage fluctuating workloads and prioritize tasks to meet deadlines and the needs of the user community; demonstrated accountability, integrity, innovation, and collaboration in a professional setting; certified Coder (preferred); bilingual translation or translation capabilities a plus.

Employment Type: Full-Time, Exempt

Work Hours: Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.

Salary: Wage Band: $84,000-95,900

Benefits: Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave; Medical, dental, and vision insurance; 401(k) with company match (fully vested immediately); Company-sponsored life insurance and additional benefits; Fitness reimbursement program; Tuition reimbursement and more

Additional Information: Inclusive Culture, Growth & Development, Work/Life Balance

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