TPA Generalist

About Crumdale Specialty :

Crumdale Specialty is a diversified insurance firm providing custom, self-funded healthcare solutions to a limited distribution network of brokers, consultants, and agents nationwide. Ranked on the Inc. 5000 Fastest Growing Companies and Best Workplaces, we leverage industry expertise, superior talent, data analytics, and a disruptive mindset to manufacture, underwrite, and administer agile, transparent, and cost-saving solutions. We optimize the fragmented health benefits supply chain to reduce health benefit costs and create better outcomes for employers and employees.

At Crumdale, people come first. We strive to make a positive impact on the people we serve. We believe this starts with the passion and purpose of our team. Our company culture is rooted in alignment, innovation, and integrity.

About the Job:

The Medical TPA Generalist supports day-to-day administration of self-funded health plans, acting as a liaison between employers, members, providers, networks, and carriers. This role is accountable for accurate eligibility and enrollment, compliant COBRA administration, precise claims processing, provider data maintenance, reporting, and general plan operations. Success looks like clean data, timely processing, regulatory compliance, and an excellent stakeholder experience.

Key Responsibilities

Eligibility & Enrollment

• Verify participant eligibility based on plan rules; maintain accurate member records across systems
• Process new hires, life events, dependents, and terminations; coordinate with HRIS/payroll for seamless integrations
• Support open enrollment—including file auditing, ID card issuance, and communications

COBRA Administration

• Identify qualifying events; send election and coverage notices within regulatory timelines
• Process elections, track premium payments, and manage reinstatements/terminations
• Maintain documentation and audit trails to ensure compliance and avoid penalties

Claims Processing & Payment

• Review and adjudicate medical (and ancillary) claims for accuracy, medical necessity, eligibility, and plan coverage
• Apply plan provisions, fee schedules, network pricing, coordination of benefits, subrogation, and benefit limits
• Issue EOBs, process payments/denials, and flag potential fraud, waste, or abuse
• Partner with vendors (e.g., repricing, PBM, stop loss) to resolve discrepancies

Plan Building & Design Support

• Set up and maintain employer plan builds, coverage tiers, and accumulators
• Assist with SPDs, plan documents, amendments, and member communications
• Validate implementations and changes for operational readiness and compliance

Provider Maintenance

• Maintain provider data (demographics, NPI/Tax ID, EFT/ERA details); manage onboarding and updates
• Coordinate with networks and repricing partners to ensure accurate discounts and routing
• Research and resolve provider payment and data issues

Reporting & Operational Support

• Manage vendor-facing technical operations by coordinating requirements, troubleshooting file integrations, and ensuring accurate claim and eligibility data exchange
• Assist in designing, modifying, and executing SQL-based processes to support operational workflows, automate data handling, and resolve system or file discrepancies
• Generate standard and ad hoc operational and claims reports for clients and internal stakeholders
• Support data validation, reconciliations, month-end close activities, and audits
• Track issues, document resolutions, and contribute to process improvements and SOPs
• Assist with utilization review coordination and cost-management analytics as needed

Customer Service & Billing

• Provide responsive support to employer groups, members, and providers with clear, empathetic communication
• Assist with billing, premium collection, cash application, and reconciliations
• Ensure adherence to ERISA, HIPAA, ACA, COBRA, MHPAEA/Parity, and applicable state mandates

Requirements

Required:

• 2–4+ years of experience in a medical TPA, health plan, or benefits administration environment (claims, eligibility/enrollment, COBRA, or provider data)
• Working knowledge of ERISA, HIPAA Privacy/Security, ACA market reforms, COBRA timelines, and general plan administration
• Proficiency with benefits administration or TPA platforms; strong Excel skills (VLOOKUP/XLOOKUP, pivot tables, data validation)
• Demonstrated attention to detail, data integrity, and documentation discipline
• Strong written and verbal communication; ability to translate plan rules into plain language

Preferred:

• Experience with plan builds, accumulators, and multiple product lines (medical, dental, vision)
• Familiarity with provider network repricing, EDI (834/835/837), and claims coding (ICD, CPT, HCPCS, revenue codes)
• Exposure to stop-loss, COB, subrogation, or utilization review concepts
• Prior work with ticketing/CRM systems and SOP creation

Tools & Systems (nice-to-have)

• TPA/benefits admin platforms (e.g., VBA, HealthEdge/Facets/QicLink/ BenefitPoint/Enrollment tools)
• EDI file handling (834/835/837), clearinghouses, and SFTP workflows
• Microsoft Excel, Word, Outlook; basic SQL or BI/reporting tools a plus (Power BI/Tableau).

Core Competencies

• Quality & Compliance: Zero tolerance for avoidable errors; maintains audit-ready records.
• Customer Focus: Clear, timely, and solution-oriented communication.
• Process Thinking: Identifies root causes; advances standardization and automation.
• Team Collaboration: Works cross-functionally with Implementation, Claims, Finance, and Client Success.
• Discretion: Handles PHI/PII in accordance with HIPAA and company policies.

Benefits

At Crumdale, we strive to provide a comprehensive and supportive benefits package to ensure the well-being of our employees. Our benefits include:

• Medical
• Telemedicine
• Dental
• Vision
• Life, AD&D, Disability
• 401(k)
• Flexible Time-off

Please note: Crumdale Specialty is not engaging with external recruitment agencies; please refrain from contacting us regarding this position.