Senior Plan Design Review & Builder, Self-Funded Healthcare Plans

Job Description

Job Description

Description:

Join our team at Cobalt Benefits Group and start an exciting new career in employee benefits solutions. As a Senior Plan Design Review & Builder , you’ll play an important role in helping us offer customized, self-funded insurance options to our clients and members.

The Senior Plan Design Review & Builder is a senior-level position responsible for reading and interpreting benefits to build out the benefit plans by coding, building, revising, and maintaining self-insured healthcare plans in the claims adjudication system. This role blends expertise in plan design and document management with the technical skills required for building and optimizing benefit plans in the system. The position requires a strong understanding of self-insured healthcare plans, regulatory compliance, and claims adjudication processes. As a senior member of the team, this individual will play a key role in ensuring that both the plan documents and the plans within the system are aligned with regulatory standards and client specifications. This role will require frequent interaction with brokers, clients and the implementation team to ensure understanding of client intent when designing and building the plan in our claims adjudication system

The Senior Plan Design Review & Builder will work closely with internal teams, including account managers, implementation teams, brokers, and client representatives, to ensure that plan documents and system builds are both accurate and compliant with federal regulations (ERISA, ACA, HIPAA). The position requires strong organizational, analytical, and communication skills to navigate complex regulatory environments and optimize plan functionality.

Key Responsibilities:

Plan Build and System Maintenance:

• Build and configure medical, dental, vision, HRA, and other benefit plans in the claims adjudication system.
• Collaborate with internal implementation teams, account managers, and other stakeholders to ensure the accurate setup of new plans and updates to existing plans.
• Troubleshoot and resolve plan build issues or errors in the claims adjudication system to ensure proper claim processing.
• Assist with the implementation of point solutions, new vendors, and claims processes to enhance operational efficiency.
• Optimize auto-adjudication processes to improve claims auto adjudication rates and reduce manual intervention.
• Assist in system release testing to ensure performance of plan build and adjudication for system upgrades
• Available to work on special projects, and upgrades which may occur over weekends.

Regulatory Compliance and Analysis:

• Serve as a subject matter expert on self-insured plan regulations and ensure plans meet both regulatory and operational standards.
• Analyze plan design changes and recommend improvements to ensure alignment with compliance standards and client requirements.
• Conduct ongoing research on evolving healthcare regulations and adjust documents and plan builds accordingly.

Collaboration and Communication:

• Work closely with internal teams, including account managers, implementation teams, and stop-loss carriers, to ensure seamless integration of plan design and system build components.
• Provide guidance to junior staff and internal teams on the proper application of plan design principles and system builds.

Requirements:

• Bachelor’s degree in Business, Healthcare Administration, Legal Studies, or a related field (or equivalent experience).
• A minimum of 5 years of experience in benefit plan documentation, system plan building, or self-insured plan administration.
• Extensive knowledge of healthcare plan documents and self-insured industry practices, including regulatory compliance requirements (ERISA, ACA, HIPAA).
• Strong technical proficiency in claims adjudication systems and plan build processes.
• Experience working with third-party administrators (TPAs), stop-loss carriers, and brokers is highly preferred.
• Exceptional analytical and problem-solving skills with the ability to work independently and handle complex plan design and system build tasks.
• Strong organizational skills and the ability to manage multiple tasks and projects with attention to detail.
• Proficiency in Microsoft Office (Word, Excel, Outlook) and familiarity with document management and claims adjudication systems.
• Excellent communication skills, with the ability to explain complex concepts clearly to internal teams, brokers, and clients.

Work Environment & Physical Demands

• Hybrid or remote work availability may be offered based on meeting key performance metrics.
• Prolonged periods of sitting may be required.
• Regular use of a computer, keyboard, and mouse is necessary; reasonable accommodations will be provided upon request.
• Employees should ensure an ergonomically appropriate desk and chair setup.
• Comfort with being on camera for virtual meetings (e.g., Microsoft Teams)

Benefits:

After successfully completing a waiting period, eligible Full-time employees have access to our comprehensive benefits package, including:

• Fantastic medical, dental, and vision insurance*
• Twice annual employer HSA contributions, covering 50% of the HDHP plan’s annual deductible!
• Company provided Basic Life and AD&D
• Company paid Short-Term and Long-Term Disability**
• Flexible Spending Accounts*
• 401(k) Retirement Plan with up to a 6% employer-match** WOW! (100% fully vested after 3 years)
• 10+ paid holidays
• Generous paid vacation and sick time
• Annual Volunteer Paid Day
• Annual Tuition Reimbursement
• Annual Health and Wellness Reimbursement
• Lots of fun company events

Who We are:

As a trusted third-party administrator (TPA) specializing in self-funded benefit plans, Cobalt Benefits Group (CBG) is committed to helping employers find high-quality coverage at a cost they can afford. We administer self-funded insurance benefits through our three companies: EBPA, Blue Benefit Administrators of Massachusetts, and CBA Blue.

With over 30 years of experience and a dedicated team of more than 200 employees, we work collaboratively to build customized self-funded health plans, manage claim payments and disputes, and administer other specialized programs such as FSAs, HSAs, COBRA, and retiree billing. Join us as we match employers across our region with the right solutions for their employee benefit needs. To learn more about working at CBG, visit

Benefit Waiting Period Notes:

*60 day waiting period

**90 day waiting period

Equal Opportunity Employer, including disability/protected veterans

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