The ideal candidate possesses deep expertise in ERISA, HIPAA, and ACA compliance, strong data analytics capabilities to evaluate claim trends, and exceptional employee communication skills to deliver a seamless experience.

Self-Insured Plan Oversight & Financial Management

• Claims Analysis & Tracking: Monitor ongoing medical and prescription drug claims performance; identify trends, high-cost claimants, and cost-driver patterns in partnership with plan actuaries and brokers.
• Stop-Loss Administration: Coordinate stop-loss policy renewals, track claims reaching individual/aggregate stop-loss thresholds, and submit reimbursement filings to carriers.
• TPA & Vendor Governance: Oversee relationships with Third-Party Administrators (TPAs), Pharmacy Benefit Managers (PBMs), and Benefits broker and carriers. Ensure operational execution according to SLAs.
• Funding & Reconciliations: Partner with Payroll and Accounting to manage weekly/monthly billing, claims funding requests, reserve requirements (IBNR tracking), and employee contribution and invoice reconciliations.

Health & Welfare Plan Administration

• Open Enrollment: Lead the annual Open Enrollment process, including system updates, open enrollment communications, employee informational sessions, and post-enrollment audits.
• Life Events & Ongoing Administration: Manage day-to-day enrollment changes, qualifying life events (QLEs), dependent eligibility verifications, and COBRA processing.
• Disability & Leave Coordination: Support short-term/long-term disability programs and align benefit premiums during active FMLA/LOA periods.

Compliance & Governance

• Regulatory Reporting: Ensure strict compliance with federal and state regulations, including ERISA, ACA (1094/1095 reporting), HIPAA, COBRA, and FMLA.
• Plan Documentation: Maintain updated Summary Plan Descriptions (SPDs), Summaries of Benefits and Coverage (SBCs), Plan Documents, and Form 5500 filings.
• Nondiscrimination Testing: Coordinate annual 105(h) and Section 125 nondiscrimination testing with third-party compliance specialists.
• Annual Benefits Audits: Lead annual 401K audit and execute dependent eligibility and enrollment audits throughout the year.

Employee Experience & Communications

• Escalated Claims Support: Act as the primary point of contact for complex, escalated employee claims issues, serving as an advocate while maintaining plan governance.
• Benefits Communication: Draft clear, accessible employee communications explaining self-insured plan features, cost-saving tools (e.g., telehealth, centers of excellence), and wellness incentive initiatives.

Your Professional Qualifications

Education & Experience

• Bachelor’s Degree in Human Resources, Business Administration, Finance, or a related field (or equivalent practical experience).
• 5 years of direct experience dedicated to health & welfare plan administration.
• Demonstrated experience managing self-insured / self-funded medical plans, including working with stop-loss insurance, TPAs, and PBMs.
• Professional Certifications (Preferred): CEBS (Certified Employee Benefit Specialist), SHRM-CP/SHRM-SCP, or PHR/SPHR.

Technical & Analytical Skills

• HRIS Proficiency: Experience administering benefits using Workday.
• Data & Excel Mastery: Advanced skills in MS Excel (Pivot Tables, VLOOKUP/XLOOKUP, data modeling) to analyze large sets of claims and census data.
• Regulatory Depth: Deep functional knowledge of ERISA, ACA, HIPAA, COBRA, and IRS Section 125 rules.