Key Responsibilities and Required Skills for Group Benefits Service Representative

🎯 Role Definition

A Group Benefits Service Representative is a customer- and detail-oriented professional responsible for administering employer-sponsored health, dental, life, disability and other ancillary benefit programs. This role handles day-to-day client and member inquiries, processes enrollments and eligibility changes, adjudicates or escalates claims issues, liaises with insurance carriers and third-party administrators, maintains accurate plan documentation, and supports renewal and audit activities. The ideal candidate combines benefits knowledge, claims administrative experience, and strong communication skills to deliver outstanding client service and ensure compliance with company protocols and regulatory requirements.

📈 Career Progression

Typical Career Path

Entry Point From:

Customer Service Representative with benefits exposure
Insurance Claims Processor or Benefits Administrator
HR Assistant or Payroll Coordinator with benefits responsibilities

Advancement To:

Senior Group Benefits Service Representative
Benefits Account Manager / Client Relationship Manager
Group Benefits Analyst or Benefits Implementation Specialist
Team Lead / Supervisor, Benefits Services

Lateral Moves:

Onboarding / Implementation Specialist (Benefits)
Broker Support or Sales Support Specialist
Claims Specialist for disability/STD/LTD lines

Core Responsibilities

Primary Functions

Serve as the primary point of contact for employer clients, brokers and plan members, responding to inbound phone, email and portal inquiries about eligibility, coverage levels, claims status, premium changes and enrollment procedures with professional and timely communication.
Conduct detailed eligibility maintenance including adding, terminating and modifying member coverage, dependents and beneficiary information within the benefits administration system and confirm updates with carriers and clients.
Coordinate and process new group plan enrollments and annual open enrollment activities, prepare enrollment kits, reconcile submissions, and follow up on missing/incomplete information to ensure accurate plan effective dates.
Review, validate and prepare submissions to insurance carriers and third-party administrators (TPAs), including eligibility files, premium adjustments, billing reconciliations and attestations to minimize processing errors and late penalties.
Investigate and resolve complex benefit and claims issues by researching plan documents, carrier guidelines and claim histories, escalating to internal specialists, carriers or clinical teams when required to achieve timely resolution.
Prepare and deliver clear coverage determinations, standard letters, confirmations, and benefit explanations to plan members and employers while documenting all client and member interactions in the CRM/claim system.
Support claim intake and triage for medical, dental, life and disability claims, ensuring proper routing, documentation, and follow up with the claims team, providers, and claimants to expedite adjudication.
Administer COBRA, leaves of absence, short-term disability and long-term disability processes where applicable, ensuring compliance with regulatory timelines and employer plan provisions.
Reconcile monthly premium billing statements, investigate variances between invoiced premiums and enrollment records, prepare adjustments and communicate necessary changes to payroll or client contacts.
Maintain up-to-date knowledge of plan provisions, insurance carrier product changes, regulatory requirements (e.g., ACA, HIPAA) and internal procedures to advise clients accurately and reduce risk.
Prepare client-facing reporting and ad hoc audits of member eligibility, participation rates and claims metrics to support account reviews, renewals and client retention strategies.
Facilitate the implementation and onboarding process for new group benefit programs, including intake of plan documents, carrier submissions, eligibility file setup, and client training on self-serve portals.
Coordinate and execute plan changes for mid-year amendments, enrollments of new hires, life event changes and terminations, ensuring audit trails and system integrity.
Manage renewals support activities by compiling participation and claims data, preparing renewal packets for brokers and employers, and assisting the renewals specialist with carrier-negotiated changes.
Liaise proactively with carriers, TPAs, payroll providers and benefit vendors to troubleshoot system errors, eligibility mismatches, or billing disputes and track resolution progress to closure.
Conduct benefit education sessions and client training (virtual or onsite) to explain plan design, enrollment tools, self-service platforms and process workflows to HR teams and plan members.
Maintain meticulous records of client plan documents, contract amendments, service level agreements (SLAs) and communication logs to support audits and regulatory requests.
Participate in internal continuous improvement initiatives to streamline benefits administration workflows, reduce processing time and improve client satisfaction metrics.
Execute data integrity checks and regular reconciliation between internal systems and carrier reports, correcting discrepancies and documenting corrective actions to maintain data quality.
Support the preparation and submission of regulatory reports and compliance documentation as required by provincial/state/federal laws or carrier requests.
Contribute to claims appeal and dispute management by assembling required documentation, drafting response letters, and coordinating with legal, clinical or underwriting teams when necessary.
Track and meet service-level agreements (SLAs) for response times, enrollment processing, escalation handling and client deliverables, prioritizing work during peak periods such as open enrollment.

Secondary Functions

Create and maintain standardized process documentation and knowledge-base articles for common inquiries and recurring tasks to improve team onboarding and consistency.
Assist benefits analysts and account managers with special projects such as vendor implementations, open enrollment campaign planning, and benefits cost modeling.
Support system testing and rollouts for benefits administration platforms by preparing test scenarios, executing test cases and reporting defects to implementation teams.
Participate in cross-functional meetings with sales, underwriting and IT to provide operational perspective on product enhancements and client requirements.
Provide backup coverage for related service roles during absences to ensure continuity of service and SLA adherence.
Collect feedback from clients and members on service experience and escalate recurring issues to management for root-cause analysis and program improvements.

Required Skills & Competencies

Hard Skills (Technical)

Proficient in benefits administration systems and HRIS platforms (examples: Workday, ADP, Microsoft Dynamics, Benefitfocus, LifeWorks, Sun Life portals, Manulife Web, GreenShield) with demonstrated ability to update eligibility and process transactions.
Strong knowledge of medical, dental, life, short-term and long-term disability product basics, claims lifecycle, coordination of benefits and typical underwriting rules.
Experience preparing and reconciling carrier premium billing files and monthly invoicing; ability to identify variances and prepare adjustment requests.
Familiarity with regulatory requirements impacting group benefits including ACA reporting, COBRA administration, FMLA/LOA processes, and PHI/HIPAA confidentiality requirements.
Ability to read and interpret insurance contracts, plan booklets, policy wording and carrier service agreements to apply correct plan rules.
Proficient with CRM and ticketing systems (e.g., Salesforce, Zendesk) to track client inquiries, escalations and SLA metrics.
Strong Microsoft Office skills with advanced Excel ability (VLOOKUP, pivot tables, data validation) for reporting and reconciliations.
Experience handling eligibility file layouts, secure data transfers (SFTP) and mapping data fields between client payroll and carrier systems.
Knowledge of claim adjudication terminology and familiarity with claim appeal processes and documentation requirements.
Exposure to benefits implementation lifecycle including intake, configuration, carrier submission, testing and training.

Soft Skills

Exceptional client-service orientation with the ability to manage difficult conversations calmly, professionally and empathetically.
Clear verbal and written communication skills capable of explaining complex benefit concepts to non-technical HR contacts and plan members.
Excellent attention to detail and organizational skills; able to manage multiple client accounts and priorities while maintaining accuracy.
Strong problem-solving aptitude with the capacity to research, identify root causes and propose practical solutions.
Collaborative team player who partners effectively with brokers, account managers, carriers and internal cross-functional teams.
Time management and prioritization skills to meet SLAs and handle peak season workloads such as open enrollment.
Discretion and integrity in handling confidential employee and client information.
Adaptability to changing plan rules, carrier systems and organizational priorities.
Analytical mindset with the ability to synthesize data into actionable insights for client communications and renewals.
Initiative to improve processes and suggest operational efficiencies based on recurring issue patterns.

Education & Experience

Educational Background

Minimum Education:

High school diploma or equivalent with demonstrated experience in benefits administration or insurance operations.

Preferred Education:

College diploma or bachelor’s degree in Business Administration, Human Resources, Insurance, Finance or a related field; or equivalent industry certifications.

Relevant Fields of Study:

Human Resources
Insurance/Risk Management
Business Administration
Finance or Accounting
Health Administration

Experience Requirements

Typical Experience Range:

2–5 years of experience in group benefits administration, customer service in insurance, claims processing or HR/benefits operations.

Preferred:

3+ years working directly with group benefit plans, carriers and TPAs, with experience supporting multiple employer accounts and open enrollment cycles.
Experience with specific carriers and benefit platforms used by your market (e.g., Sun Life, Manulife, Green Shield, Great-West Life, TELUS Health, Benefitfocus).
Certifications or continuous education in benefits or insurance (e.g., CBP — Certified Benefits Professional, HR certifications, or carrier-specific training) are an asset.