The Role
Oversee TPA performance, ensure claims and benefits are processed accurately and compliantly, resolve escalated claims, manage provider contract distribution and benefit configurations, lead audits and process improvements, and report performance to leadership.
Summary Generated by Built In
CONTRACTING SPECIALIST BENEFITS AND CLAIMS
HYBRID, must be able to travel to 3031 NE STEPHENS ST. ROSEBURG, OR 97470
EMPLOYMENT TYPE: Full-Time, Exempt
About Umpqua Health
POSITION PURPOSE
The Benefit and Claims Oversight Specialist is responsible for ensuring accurate, timely, and compliant administration of health plan benefits and claims through Umpqua Health’s Third-Party Administrator (TPA). This role does not supervise internal staff but holds full oversight responsibility for TPA performance, compliance, and adherence to contractual and regulatory requirements. The position also manages provider contract distribution, benefit administration communications, and interpretation of contract requirements. Acting as the primary liaison between Umpqua Health and the TPA, this role drives accountability, resolves claims issues, and supports organizational goals for quality and efficiency.
ESSENTIAL JOB RESPONSIBILITIES
TPA Oversight & Compliance
- Oversee Third-Party Administrator (TPA) performance, ensuring accuracy, timeliness, and adherence to service-level agreements.
- Lead audits and compliance reviews to ensure alignment with federal and state regulations, contractual obligations, and organizational standards.
- Manage and resolve escalated claims and benefit issues, ensuring timely and effective outcomes.
- Oversee distribution, tracking, and validation of provider contracts to ensure accuracy and compliance.
- Interpret and operationalize Oregon Health Authority (OHA) and Umpqua Health Network (UHN) contractual requirements.
- Ensure accurate configuration and maintenance of benefits, fee schedules, and authorization rules within claims systems.
- Direct data integrity efforts across TPA and internal systems, ensuring consistent application of business rules.
- Provide leadership in the resolution of complex claims issues, disputes, and exceptions.
- Ensure accurate interpretation and application of benefit structures by the TPA.
- Serve as a key escalation point for internal teams and external partners.
- Develop and implement policies and procedures to strengthen claims oversight and benefit administration.
- Identify operational gaps and lead process improvement initiatives to enhance efficiency, accuracy, and compliance.
- Serve as the primary liaison for TPA-related performance and escalation matters.
- Deliver regular reporting, insights, and strategic recommendations to leadership.
- Perform other duties as assigned.
CHALLENGES
- Working with a variety of personalities, maintaining a consistent and fair communication styles.
- Satisfying the needs of a fast-paced and challenging company.
MINIMUM QUALIFICATIONS
- Bachelor’s degree in healthcare administration, Business, or a related field required
- Minimum of 5 years of experience in health plan claims processing and benefit administration, preferably with TPA oversight responsibilities
- Strong understanding of managed care operations and regulatory compliance
- Proficiency in claims systems and Microsoft Office Suite
- Strong analytical and problem-solving skills
- Excellent verbal and written communication skills, including negotiation abilities
- Ability to manage vendor relationships and enforce accountability
- Ability to analyze and interpret data to determine appropriate configuration changes
- Ability to accurately interpret state and/or federal benefits, contracts, and additional business requirements and translate them into configuration parameters
- Ability to coordinate and facilitate coding updates related to benefit plans, provider contracts, fee schedules, and system tables through the user interface
- Ability to apply previous experience and knowledge to research and resolve claim and encounter issues, including pended claims, and communicate system update needs to TPAs
- Ability to manage fluctuating workloads and prioritize tasks to meet deadlines and the needs of the user community
- Demonstrated accountability, integrity, innovation, and collaboration in a professional setting
- Certified Coder (preferred)
- Bilingual translation or translation capabilities a plus
Monday through Friday - 8:00am - 5:00pm; standard business hours with flexibility to meet service timelines.
SALARY
Wage Band: $84,000-95,900
BENEFITS
- Salary is dependent on skills, experience, and education
- Generous benefits package including vacation PTO, sick leave, federal holidays, and birthday leave
- Medical, dental, and vision insurance
- 401(k) with company match (fully vested immediately)
- Company-sponsored life insurance and additional benefits
- Fitness reimbursement program
- Tuition reimbursement and more
Why Umpqua Health?
We are committed to advancing health equity by collaborating across communities, addressing systemic barriers, and ensuring fair access to care and resources. At Umpqua Health, every team member plays a vital role in making a meaningful impact, empowering healthier lives and strengthening the communities we serve.Inclusive Culture
We foster a respectful, inclusive environment where employees feel valued, supported, and empowered.
Growth & Development
We support ongoing learning through mentorship, clear career pathways, and professional development opportunities.
Work/Life Balance
We promote flexibility and well-being so employees can thrive both professionally and personally.
Equal Opportunity
Umpqua Health is an equal opportunity employer that embraces individuals from all backgrounds. We prohibit discrimination and harassment of any kind, ensuring that all employment decisions are based on qualifications, merit, and the needs of the business. Our dedication to fairness and equality extends to all aspects of employment, including hiring, training, promotion, and compensation, without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, veteran status, or any other protected category under federal, state, or local law.Skills Required
- Bachelor's degree in healthcare administration, Business, or related field
- Minimum of 5 years experience in health plan claims processing and benefit administration with TPA oversight
- Strong understanding of managed care operations and regulatory compliance
- Proficiency in claims systems
- Proficiency in Microsoft Office Suite
- Strong analytical and problem-solving skills
- Excellent verbal and written communication skills, including negotiation abilities
- Ability to manage vendor relationships and enforce accountability
- Ability to analyze and interpret data to determine appropriate configuration changes
- Ability to accurately interpret state and/or federal benefits and contracts and translate into configuration parameters
- Ability to coordinate and facilitate coding updates related to benefit plans, provider contracts, fee schedules, and system tables through the user interface
- Ability to research and resolve claim and encounter issues, including pended claims, and communicate system update needs to TPAs
- Ability to manage fluctuating workloads and prioritize tasks to meet deadlines
- Demonstrated accountability, integrity, innovation, and collaboration
- Certified Coder
- Bilingual translation or translation capabilities
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The Company
What We Do
Umpqua Health is a mission-driven, community-focused healthcare organization and Coordinated Care Organization (CCO) based in Roseburg, Oregon. It coordinates care for Oregon Health Plan members across Douglas County, providing integrated primary, behavioral, dental, and urgent care through its Umpqua Health Alliance and Newton Creek Clinic while focusing on whole-person care, care coordination, and community health programs.
