AI-Driven Operations Specialist

Evolving Solution Services; Seattle (WA); On-site; USD 83,097,000 - 103,155,000; Full time

Benefits offered by this job

Health Insurance

401(k) with employer match

Tuition Reimbursement

PTO and Holidays

Job summary

First Choice Health, headquartered in Seattle, seeks an Operations Specialist to manage enrollment, eligibility, and COBRA processes for self-funded employer clients. You will automate data workflows, ensure 100% compliance, and craft clear appeal determinations.

Ideal candidates bring 2+ years in TPA/benefits administration, strong ERISA knowledge, and hands-on AI/automation experience, with proficiency in Excel and TPAs. Seattle-based, full-time role with growth opportunities.

Qualifications

• 2+ years of experience in TPA operations, benefits administration, or medical claims.
• Solid understanding of ERISA, COBRA, HIPAA, and PPACA regulations for self-funded group health plans.
• Experience with TPA administration platforms (e.g., LuminX, Eldorado/Javelina, WLT) and advanced Excel (VLOOKUP/XLOOKUP, Pivot Tables, Power Query).
• Practical experience utilizing AI tools (like ChatGPT, Claude, Gemini, or Copilot) to draft correspondence, summarize complex information, or analyze tabular data.

Responsibilities

• Automate ingestion and validation of weekly EDI 834 enrollment files from clients, brokers, and ben-admin platforms.
• Investigate and resolve eligibility discrepancies to prevent coverage gaps.
• Oversee audits of system builds to ensure digital eligibility rules match SPD.
• Oversee automation of COBRA communication generation, mailing, and tracking within ERISA timelines.
• Manage COBRA premium structures, severance and retroactive reinstatements.
• Draft legally defensible appeal determination letters and coordinate with stop-loss carriers on high-dollar appeals.
• Identify repetitive tasks and build automated AI/low-code solutions to reduce turnaround times.

Skills

TPA operations

Benefits administration

Medical claims

AI tools usage

Excel (VLOOKUP/XLOOKUP/Pivot)

Workflow automation

Tools

LuminX

Eldorado/Javelina

WLT

Job description

First Choice Health, headquartered in Seattle, seeks an Operations Specialist to manage enrollment, eligibility, and COBRA processes for self-funded employer clients. You will automate data workflows, ensure 100% compliance, and craft clear appeal determinations.

Ideal candidates bring 2+ years in TPA/benefits administration, strong ERISA knowledge, and hands-on AI/automation experience, with proficiency in Excel and TPAs. Seattle-based, full-time role with growth opportunities.