Claims and Implementation Specialist - Remote
OneDigitalAbout the role
Employee Benefits is the core of our business and at our heart we are a people-focused organization. Every day, we help over 100,000 employers give their employees peace of mind by providing health, pharmacy, long and short-term disability, vision, dental and other insurance solutions. What makes us unique is that we can surround our clients with more services and more technology-based tools and a team of advisors that simply cares more than anyone else.
If you want a career giving people the reassurance that they can have access to the health care they need for themselves and their loved ones, join OneDigital.
Our Newest Opportunity:
The OneDigital Self-Funded Center of Excellence (SFCOE) provides OneDigital offices with a full suite of self-funding solutions and support, including traditional stop loss, captives, level-funded options, and TPA (ASO) marketing. Our goal is to match each client with the right self-funded strategy based on their risk-profile while reducing complexity for the field and ensuring clients receive competitive pricing and best-in-class contract terms.
The Claims and Implementation Specialist, Self-Funded Solutions is responsible for coordinating the post-sale implementation and onboarding of new stop loss, captive, and self-funded benefit programs. Serving as a key liaison between clients, consultants, TPAs, stop loss carriers, captive managers, and internal stakeholders, this role ensures a seamless onboarding experience while helping to design, enhance, and improve operational processes that support the Self-Funded Center of Excellence. The specialist will coordinate across multiple internal teams and external partners to streamline workflows, improve service delivery, drive operational consistency, and support the successful administration of self-funded programs through ongoing claims monitoring, reimbursement tracking, and carrier reporting activities.
Essential Duties and Responsibilities (include but are not limited to):
Manage post-sale implementation of new stop loss, captive, level-funded, and self-funded programs.
Develop, maintain, and oversee implementation timelines and project plans.
Coordinate onboarding activities between employers, consultants, TPAs, stop loss carriers, captive managers, and vendor partners.
Facilitate implementation meetings and provide regular status updates to stakeholders.
Ensure completion and submission of all required implementation documentation, applications, contracts, and enrollment materials.
Report all members that exceed 50% of the specific deductible to the stop loss vendor.
Submit eligible paid claims to the excess loss vendor.
Submit eligible Advanced Funding requests to the excess loss vendor
Maintain claims system of record data to track the submissions for turn-around of payment by the excess loss vendor.
Update and maintain company databases, including D365
Verify and post all payments received from the excess loss vendor in the claim system.
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