People Services And Benefits Specialist II

Benefits

Additional Information

Maryville, TN The People Services and Benefits Specialist II is the advanced escalation expert for benefits and member care. This role resolves complex claims issues, delivers high touch concierge navigation for Team Members and dependents, leads audits and compliance activities, maintains plan documents, and policies. The Senior combines deep benefit plan knowledge with strong Workday proficiency and operational rigor to ensure the right care, at the right time, at the right cost-with minimal friction for Team Members. People Services and Benefits Specialist II Job Duties Serve as the escalation for complex medical, pharmacy, dental, vision, COBRA, and similar benefit claims (e.g., prior authorization denials, coordination of benefits, appeals, out‑of‑network cases). This role owns complex, high-risk benefits cases from intake through full resolution, including proactive follow-up to ensure outcomes such as claims reprocessing, authorizations, and billing corrections. This role uses their knowledge and experience to recommend the most appropriate and effective way for a Team Member to navigate their care. Proactively review Team Member benefit enrollments and ensure they understand all available benefit options, for example, guiding a Team Member to file a hospital or critical illness claim when appropriate. Provide concierge advocacy by coordinating directly with carriers-leveraging warm transfers, three‑way calls, and direct outreach-to resolve issues without assigning follow‑up tasks to the Team Member. Offer end‑to‑end care navigation (benefit verification, referral support, prior authorization troubleshooting, coordination with other benefit enrollments), ensuring the Team Member always knows what happens next. Deliver personalized, empathetic guidance for sensitive or ongoing medical situations and remain the single point of contact until full resolution. Monitor high‑risk or high‑cost cases and proactively engage affected Team Members with education and navigation support. Identify root causes and recommend vendor or process improvements to reduce recurrence. Strong understanding in overall benefit strategy to ensure programs are effectively communicated and delivered to Team Members during interactions. The role will translate benefit strategy into guidance for TMs that align with our values/priorities. Track active cases end-to-end; proactively intervene when delays, errors, or denials are detected-aiming to prevent surprise bills or care disruptions. Conduct follow-up outreach to confirm care was received, referrals/authorizations approved, prescriptions filled, claims reprocessed, and balances corrected before closing cases. Analyze recurring provider or carrier issues and escalate trend insights with recommended remediation steps. Educate and train Specialists how to complete audits and monitor success rates of recurring benefits and data integrity audits (completed by specialists), as defined by leadership. If audit fails, own resolution process including leadership updates and provide recommendation for improvements. Compliance strategy defined by manager. Monthly Badge Audit Monthly Disabled Dependent Audit Quarterly P-file access review (sent to HRBPs) This role should recognize new topics for audit, enhance the effectiveness of existing audits, and identify areas where audits may no longer have an ROI. Execute assigned work tied to the yearly business cycle, such as year-end tasks or seasonal benefit work, such as ACA, open enrollment, etc. Process weekly Tennessee New Hire Report filing and similar items Advanced knowledge to lead Subpoena and Background Investigation requests, and support written Verifications of Employment High knowledge of outsourced 3rd party vendor for Verifications of Employment Review annual plan documents such as SPDs/SBCs, and similar plan documents; interpret complex plan language, resolve discrepancies, partner with external legal counsel, and ensure documentation remains compliant and reflective of plan design intent. Maintain document storage is maintained per retention policies. Provide leadership summary, recommended changes, and feedback for final approval. Coordinate changes and/or approvals with legal and leadership; ensure alignment to current plan design and process updates. Support plan governance tasks, ex. required filings or communication deadlines Ensure team member handbooks and new hire packets are up to date with relevant benefit plan documents. Act as a Workday superuser for benefits processes (life events, eligibility, corrections, job/comp changes impacting benefits) and complex case troubleshooting; partner with Benefit Operations on data fixes. Partners closely with Benefit Operations to perform user acceptance testing (UAT) for benefits configuration and file feeds; document defects and retests; publish training materials for team or Team Members, as needed. Build and run quality and exception reports; lead remediation and coach the tea