The Administrative Operations Specialist supports the daily administrative operations of self-funded medical, dental, vision, and pharmacy benefit plans. This role assists with vendor setup, eligibility and claims file management, provider refund recovery, claim payment support, vendor invoicing, COBRA premium tracking, and monthly reporting support.
This position works closely with the eligibility, invoicing, claims, reporting, finance, and vendor management teams to ensure health plan data, payments, files, and operational processes are completed accurately and timely.
Key Responsibilities
- Coordinate provider refunds when claim overpayments occur, including requesting recoupment from providers, tracking outstanding refunds, and documenting funds received.
- Assist with setup of health plan vendors, including PBMs, utilization management vendors, COBRA vendors, stop-loss partners, and other point solution vendors.
- Coordinate setup and maintenance of eligibility and claims feeds with vendors.
- Import, upload, and validate eligibility and claims files received from clients and vendors.
- Assist the eligibility team with receiving weekly eligibility files from clients, importing files into the system, and maintaining accurate eligibility data.
- Help identify and resolve file errors, missing data, formatting issues, and eligibility discrepancies.
- Support claim payment processes, including facilitating check runs for medical, dental, and vision insurance plans.
- Assist with review and payment of pharmacy, COBRA, stop-loss, utilization management, and other vendor invoices.
- Track invoice status, payment timing, and supporting documentation.
- Learn, document, and assist with COBRA premium payment processes and related COBRA operations.
- Record COBRA payment activity and coordinate with internal teams to maintain accurate COBRA records.
- Assist the reporting team with pulling and preparing monthly reporting for clients, brokers, and stop-loss carriers.
- Gather claims, eligibility, pharmacy, and vendor data needed for recurring reports.
- Assist with requesting additional records from providers when needed to support claims processing.
- Maintain process documentation for recurring operational tasks.
- Support multiple internal departments, primarily invoicing, eligibility, reporting, claims, and vendor operations.
Required Skills and Qualifications
- Strong attention to detail and accuracy.
- Ability to manage recurring tasks and follow up on open items.
- Strong organizational and time management skills.
- Comfortable working with spreadsheets, invoices, data files, and system imports.
- Ability to identify errors, missing information, and process inconsistencies.
- Strong written and verbal communication skills.
- Ability to work across multiple departments and support competing priorities.
- Ability to handle sensitive member, provider, and client information confidentially.
- Willingness to learn health plan operations, vendor feeds, COBRA processes, claims payment workflows, and reporting procedures.
Preferred Experience
- Experience in health plan administration, TPA operations, employee benefits, medical claims, eligibility, billing, accounting, or vendor coordination.
- Familiarity with medical, dental, vision, pharmacy, COBRA, PBM, utilization management, or stop-loss operations.
- Experience working with eligibility files, claims files, vendor invoices, provider refunds, or client reporting.
- Proficiency in Excel or similar spreadsheet tools.
Core Competencies
- Detail-oriented
- Organized
- Reliable follow-through
- Process-driven
- Data accuracy
- Confidentiality
- Cross-functional communication
- Problem-solving
- Willingness to learn
- Time management
Pay: $19.00 - $21.00 per hour
Benefits:
- Dental insurance
- Life insurance
- Paid time off
- Vision insurance
Work Location: In person
