TPA Operations Specialist

HUB International•Ridgeland, MS

1d•Onsite

About The Position

The TPA Operations Specialist is a critical operational role within our Healthcare Third-Party Administrator (TPA) organization. This position is responsible for the accurate and timely execution of client claims funding activities, including weekly check register duties and multi-line claims invoicing across medical, prescription, and dental benefits. In addition, the Specialist supports a broad range of TPA duties. This role requires a detail-oriented professional who thrives in a fast-paced, deadline-driven healthcare environment.

Requirements

Associate’s degree in Business Administration, Finance, Health Information Management, or a related field required.
Minimum 2 years of experience in a healthcare TPA, managed care, or health insurance operations environment.
Demonstrated experience with claims funding, benefit plan building in claims adjudication system, and healthcare billing and invoicing.
Proficiency with SFTP clients and secure file transmission protocols.
High degree of accuracy and attention to detail in financial and data entry tasks.
Ability to manage multiple priorities and meet recurring deadlines in a dynamic environment.
Proficiency with Microsoft Office Suite, particularly Excel (pivot tables, VLOOKUP, data validation).
Working knowledge of HIPAA regulations and healthcare data privacy requirements.
Strong written and verbal communication skills for client-facing interactions.

Nice To Haves

Bachelor’s degree preferred.
Familiarity with claims adjudication systems (e.g., Javelina, Healthpac, AS400) preferred.
Experience with benefit plan configuration or enrollment administration is highly desirable.
Extensive knowledge base in the overall operations of a healthcare TPA.
Experience with EDI file formats (834, 837, 835) used in healthcare data exchange.
Familiarity with pharmacy benefit manager (PBM) interfaces and Rx claims processing.
Prior exposure to dental claims adjudication or dental benefit plan administration.

Responsibilities

Perform the client's weekly check register, reporting, and funding process requirements.
Respond to customer inquiries regarding weekly electronic fund transfers (EFTs) and ACH transactions, including vendor reports.
Ensure that accurate funding transmittals for medical, prescription (Rx), and dental claims are sent to clients on established funding cycles. This would include detailed check registers and claim reports as requested by a client.
Reconcile FBO funding accounts and resolve discrepancies between claims payments, client deposits, and issued invoices.
Monitor funding thresholds and communicate proactively with clients regarding insufficient funding or pending shortfalls.
Monitor outstanding funding requests to ensure funding is received and checks are released timely.
Maintain accurate financial records and documentation in support of audit and compliance requirements.
Build and configure benefit plan structures within the claims adjudication platform, including coverage tiers, deductibles, copays, coinsurance, and out-of-pocket limits.
Translate client Summary Plan Descriptions (SPDs) and benefit summaries into accurate system configurations.
Perform testing and validation of new or modified benefit plan configurations prior to go-live and ongoing basis.
Utilize CRM for all plan-build documentation and change logs to support compliance, auditing, and client reporting for account manager access.
Utilize CRM for implementation of new clients with account management and implementation teams during new client onboarding and annual open enrollment periods.
Assist in the configuration of provider networks and benefit hierarchy structures within the adjudication system to ensure accurate claims routing and processing by plan design. This would include Baseload rule implementations.
Assist on 1099 annual documentation requests.
Respond to CRM Tasks Assigned in a timely manner.
Contribute to process improvement initiatives to enhance accuracy, efficiency, and client satisfaction.
Assist with special projects and cross-functional initiatives as assigned by management.
Adhere to all HIPAA privacy and security regulations governing the handling of Protected Health Information (PHI).
Assist in the process member eligibility additions, terminations, and changes within the claims adjudication system in accordance with client instructions and regulatory timelines.
Back up and assist - Perform scheduled and ad-hoc SFTP file transfers, including eligibility feeds, claims data, remittance files, and reporting outputs.
Monitor file error reports and assist in resolving errors.
Assist as needed in maintaining SFTP directory structures, access credentials, and transmission schedules in coordination with EDI Director.