Health Plan SME

Job Summary

The client is seeking an experienced Health Plan ASO Product Configuration & Benefits SME to support the design and implementation of a new ASO / self-funded commercial health plan offering.

Key Responsibilities

• Lead structured product and benefit working sessions to define detailed ASO product decisions and implementation requirements.
• Break down high-level product concepts into specific decisions related to:
  • Included and optional services
  • Eligibility
  • Benefit configuration
  • Exclusions and exceptions
  • Employer-selectable options
  • Customization parameters
  • Vendor selections
• Apply strong ASO market knowledge to identify product and configuration decisions that may not yet have been fully defined.
• Distinguish between standard product configuration, employer-selectable options, configurable parameters and true exceptions/customizations.
• Identify dependencies across benefits, claims, eligibility, network, pharmacy, clinical programs, billing, reporting, stop loss and vendor administration.
• Maintain clear decision logs, issue tracking, dependencies and accountable owners.

Benefits & Configuration Design

• Define the detailed benefit architecture supporting the ASO offering.
• Document configurable benefit attributes including:
  • Deductibles
  • Copays
  • Coinurances
  • Out-of-pocket maximums
  • Accumulators
  • Service and visit limits
  • Network tiers
  • Medical/Rx integration
  • Exclusions
  • Benefit-specific business rules
• Establish configuration guardrails defining what is:
  • Standard
  • Employer-selectable
  • Configurable with approval
  • Outside the standard product
• Define employer and group-level configuration requirements across plan, population, benefit package and network structures.
• Help establish reusable benefit packages and templates to reduce one-off group customization.
• Identify downstream implications for plan documents, Clients, benefit summaries and other configuration-driven outputs.

Requirements & Implementation Support

• Translate approved product and benefit decisions into clear, testable business and functional requirements.
• Define business rules, configuration logic, data requirements, process requirements, integrations, controls and vendor dependencies.
• Develop acceptance criteria and scenarios demonstrating how benefit and configuration rules should operate across employer and member situations.
• Maintain traceability from product decision → business rule → configuration requirement → acceptance criteria.
• Partner with technology and configuration teams to ensure requirements contain sufficient detail for implementation.
• Identify downstream claims-adjudication and system configuration implications of benefit decisions.
• Support issue resolution where product intent, operational requirements and platform capabilities are not aligned.

Required Skills

• 8–15 years of experience within commercial health plans, payer operations, product configuration, claims or benefits administration.
• Significant hands-on experience with ASO / self-funded health plan products.
• Deep understanding of commercial medical benefit design and administration, including:
  • Deductibles
  • Out-of-pocket maximums
  • Copays
  • Coinurances
  • Accumulators
  • Benefit limits
  • Exclusions
  • Network-tier logic
• Experience with ASO product configuration and employer-group customization.
• Demonstrated experience translating benefit and product designs into configuration specifications, detailed requirements or claims-adjudication rules.
• Experience working with major payer core administration environments such as HealthRules, Facets, QNXT or similar platforms.
• Strong understanding of the interactions between:
  • Benefits
  • Claims
  • Eligibility
  • Network
  • Pharmacy
  • Clinical programs
  • Stop loss
  • Billing
  • Employer reporting
• Strong experience developing configuration matrices, benefit specifications, business rules, use cases and acceptance criteria.
• Strong documentation, stakeholder management and communication skills.

Preferred Skills

• Candidates may come from roles such as: Director / Lead, Product Configuration
• Benefits Configuration Lead
• ASO Product Implementation Lead
• Claims & Benefits Configuration SME
• Senior Product Configuration Consultant
• Payer Product / Benefits Solution Architect

About GTT

GTG is a minority-owned staffing firm and a subsidiary of Chenega Corporation, a Native American-owned company in Alaska. We highly value diverse and inclusive workplaces and support Fortune 500 organizations across banking, financial services, technology, life sciences, biotech, utilities, and retail sectors throughout the U.S. and Canada.