Job Description

Required Qualifications

· Bachelor’s degree in Finance, Healthcare Administration, Business, or related field

· 5–10+ years of experience in benefits, claims analysis, or payer-side operations

· Strong understanding of:

o Medical and pharmacy claims

o Claims adjudication and payer methodologies

o Self-funded plans and stop-loss mechanics

o Benefits administration and billing processes

· Advanced Excel and data analysis skills

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Preferred Qualifications

· Experience with a major health insurer (BCBS experience strongly preferred)

· Experience working with TPAs, stop-loss carriers, and pharmacy benefit managers

· Experience supporting or managing benefits within a self-funded employer environment

Qualifications

The Senior Benefits Claim Analyst is responsible for the day-to-day administration and ongoing optimization of the company’s health and welfare benefits programs, with a strong emphasis on claims analytics, financial oversight, and vendor performance validation.

This role combines hands-on operational ownership with deep analytical capability to ensure the accuracy, integrity, and performance of the company’s self-funded health plans. The Analyst will manage benefits administration while also evaluating claims data, validating carrier performance, and identifying opportunities to reduce cost and improve plan efficiency.

This role serves as a key execution and analytical partner to the Director of Benefits, providing data-driven insights and operational oversight that inform strategic decisions, vendor management, and plan design.---

Key Responsibilities

Benefits Administration & Process Optimization

· Own and execute day-to-day administration of health and welfare benefit programs, including enrollments, life events, eligibility, and employee support

· Ensure accurate data flow between HRIS/payroll systems (e.g., ADP) and carriers

· Manage benefits billing and eligibility alignment across systems

· Maintain compliance with ACA, COBRA, HIPAA, and other applicable regulations

· Identify opportunities to improve processes, reduce manual work, and increase accuracy

· Evaluate and support implementation of scalable solutions (e.g., managed benefits platforms) to enhance efficiency over time

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Claims Analytics & Cost Management

· Analyze medical and pharmacy claims data to identify trends, cost drivers, and emerging risks

· Evaluate high-cost claims, utilization patterns, and stop-loss exposure

· Identify opportunities for cost containment and plan optimization

· Develop recurring reporting on claims performance and financial impact

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Financial Oversight & Billing Accuracy

· Review and validate carrier invoices, claims reports, and funding requirements

· Reconcile discrepancies between claims activity, eligibility, and billing

· Provide support on forecasting and budgeting through data-driven insights

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Vendor Accountability & Payer Management

· Serve as primary contact for day-to-day vendor interactions, claims issues, and data validation

· Interpret payer methodologies, adjudication logic, and contract terms

· Identify, investigate, and challenge inaccuracies in carrier and PBM reporting

· Escalate material issues, trends, and performance concerns to the Director of Benefits

· Support vendor management by validating performance and ensuring alignment with contractual expectations

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Complex Issue Resolution

· Escalate complex or high-dollar claims and benefits issues to the Director of Benefits

· Conduct root cause analysis and implement long-term solutions

· Partner with vendors to resolve discrepancies and prevent recurrence

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Strategic Partnership

· Provide data-driven insights to inform cost management strategies and plan design decisions led by the Director of Benefits

· Support renewals, audits, and vendor evaluations through detailed analysis and reporting

· Bring a payer-side perspective to strengthen internal decision-making