People Services And Benefits Specialist II at Clayton in Maryville, TN

People Services And Benefits Specialist II Location: Maryville, TN The Team Member Services Senior 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. Team Member Services Senior 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 team on prevention. Draft clear, empathetic communications for escalations, team member updates, and leadership briefings; develop talking points and knowledge content for Generalists and Specialists to ensure consistent, accurate messaging. Identify opportunities to elevate the Team Member experience by partnering with the Benefits Program team to promote benefits offerings and reinforce the benefits strategy through consistent, impactful interactions with Team Members. Serve as a go-to advisor for Generalists and Specialists on complex scenarios; provide case quality feedback and share best practices. Such as: Conducting regular case/peer review sessions with Generalists and Specialists to debrief complex escalations and share resolution approaches Maintaining the team’s KB articles, guides, etc. Provide structured onboarding support for new members of the team on benefit processes, Workday support, etc. Identify trends in claims, tickets, and knowledge gaps; recommend process and vendor improvements to enhance the Team Member experience. Team Member Services Senior Requirements Strong knowledge of medical/pharmacy plan design, claims adjudication, appeals, and coordination of benefits; familiarity with dental/vision/disability/COBRA processes. Demonstrated proficiency with Workday (or comparable HRIS) for benefits transactions, corrections, reporting, and troubleshooting. Proven ability to resolve high complexity, high sensitivity cases with confidentiality and professionalism. ‑complexity, high‑sensitivity cases with confidentiality and professionalism. Excellent written and verbal communication; strong documentation and stakeholder management skills. Preferred Experience coordinating with major carriers/TPAs and vendor file interfaces (eligibility, payroll, EDI). Background in audits/compliance (ERISA/ACA concepts), plan document stewardship, or vendor performance management. Bachelor’s degree in HR, Business, or related field Education: High School Diploma or Equivalent - Bachelor’s degree in HR, Business, or related field preferred Years of Related Experience: 5+ years in benefits administration, health plan operations, or HR service center roles with advanced claims and member navigation experience Team Member Services Senior Competencies Member Advocacy & Empathy Benefits & Claims Expertise Judgment & Risk Management Systems & Data Integrity Process Improvement Influence & Communication Collaboration Confidentiality & Integrity Why Clayton? Full-time team members have the flexibility to create their own health, dental, and vision benefits package. Clayton provides competitive 401K programs, including investment options and company matching for full and part time team members after one year to help our team members achieve their financial goals. Additional benefits include paid parental leave, tuition reimbursement, Employee Assistance Programs, and more. As part of Clayton’s commitment to Opening Doors to a Better Life, Clayton is now providing paid time for Team Members to volunteer to causes that are meaningful to them through the Clayton Impact program. At Clayton, we encourage holistic wellness with physical, nutritional, social, financial, spiritual and occupational programs available online or in-person for team members. Clayton’s Home Office campus offers an onsite restaurant, onsite fitness facility with full gym, in-person and virtual workout classes, yoga / barre studio, volleyball and basketball courts, walking paths, and a disc golf course. Clayton is committed to creating an inclusive workplace. Clayton is an equal opportunity employer and does not discriminate on the basis of race, national origin, gender, gender identity, sexual orientation, protected veteran status, disability, age, or other legally protected status. Compensation Grade Pay Range $66,495.00 - $83,115.00 Business Unit - B00015 HomeTeam