IntePros is hiring: Claims Operations Specialist (Philadelphia) in Philadelphia

The Claims Operations Specialist serves as a key liaison between the business and multiple internal departments, ensuring accurate benefit configuration and timely resolution of benefit-related inquiries. This role supports all lines of business and market segments, including Fully Insured and Self-Funded plans, and plays a critical role in maintaining benefit accuracy, operational alignment, and customer satisfaction.

Key Responsibilities

• Act as the primary point of contact for benefit-related tickets submitted by Customer Service, Operations, Claims, Sales, Member Appeals, and Executive teams.
• Review, triage, and manage incidents across all lines of business and market segments, ensuring resolution within established internal SLAs.
• Conduct in-depth research across multiple systems to validate client, product, and benefit setup.
• Utilize core applications such as FOS, CSIW, Health Rules Payor, and Product Configurator to investigate and resolve benefit discrepancies.
• Analyze benefit rules and configurations to identify root causes and recommend corrective actions.
• Prepare clear, accurate, and professional written responses with supporting documentation for key, high-visibility, and executive-level inquiries.
• Facilitate cross-functional discussions to align stakeholders on benefit rules, configuration, and interpretation.
• Ensure consistent understanding and application of benefit logic across departments.

Qualifications

• Bachelors degree or equivalent relevant experience.
• 35 years of related professional experience.
• 4+ years of health insurance claims processing experience.
• Strong analytical and problem-solving skills with the ability to interpret complex benefit structures.
• Proven ability to communicate complex concepts clearly to both technical and non-technical audiences.
• Proficiency in Microsoft Office applications.