Role: Health Plan ASO Product Configuration & Benefits SME
Location: USA (Remote)
Duration: 6+ months
Role purpose
The ASO Product Configuration & Benefits SME will lead the detailed definition and documentation of product, benefit, and configuration decisions required to launch a new ASO offering. This individual will work across Product, Benefits, Claims, Configuration, Operations, Technology, Clinical, Pharmacy, Network, Legal/Compliance, Sales, and vendor teams to translate high-level product strategy into specific product selections and implementable business requirements.
The resource should bring hands-on experience designing and configuring commercial health plan products—particularly ASO/self-funded products—and understand how benefit design decisions ultimately translate into claims administration and core platform configuration.
Key responsibilities
1. Drive detailed PADU/product selection working sessions (preferred / acceptable / discouraged / unacceptable)
- Facilitate structured working sessions with Product and functional SMEs to define detailed ASO product decisions.
- Decompose high-level product components into the specific decisions required for implementation: included services, optional services, eligibility, configuration choices, exclusions, exceptions, customization parameters, vendor selections and commercial treatment.
- Bring leading-practice ASO product knowledge to identify decisions the organization may not know it needs to make.
- Distinguish between standard product configuration, employer-selectable options, configurable parameters, and true exceptions/customizations.
- Identify dependencies between benefit decisions and claims, network, pharmacy, clinical programs, eligibility, billing, reporting and vendor administration.
- Maintain decision logs, open issues, dependencies and accountable owners.
2. Define the ASO benefits and configuration model
- Define the detailed benefit architecture supporting the ASO product.
- Document configurable benefit attributes including deductibles, coinsurance, copays, out-of-pocket maximums, accumulators, visit/service limits, network tiers, medical/Rx integration, exclusions and benefit-specific rules.
- Establish the configuration hierarchy and guardrails—what is standard, selectable, configurable with approval, or outside the product.
- Define employer/group-level configuration requirements and identify where configuration varies by group, plan, benefit package, network or population.
- Help establish reusable benefit packages/templates rather than relying on one-off group configuration.
- Identify implications for plan documents, SBCs, benefit summaries and other configuration-driven outputs.
3. Translate approved product decisions into detailed requirements
- Convert approved PADU/product decisions into clear, testable business and functional requirements.
- Document business rules, configuration logic, data requirements, process requirements, system impacts, integrations, controls and vendor dependencies.
- Develop acceptance criteria and scenarios demonstrating how requirements should operate for different employer and member situations.
- Trace requirements back to approved product decisions so implementation teams can distinguish product intent from implementation interpretation.
- Partner with technology/configuration teams to ensure requirements contain sufficient detail for configuration and development.
4. Bridge Product and technical configuration teams
The person should be able to take a product statement such as: “Employers may select among three deductible levels with integrated medical/Rx accumulators and optional out-of-network coverage.” …and drive it down to the next level: permitted deductible values, individual/family logic, embedded versus aggregate rules, accumulator behavior, network applicability, Rx interaction, exception rules, group-level configuration attributes, claims-system implications, documentation requirements and acceptance criteria.
Required experience
8–15+ years of commercial health plan experience, with significant hands-on experience in ASO/self-funded product implementation, benefits configuration, or claims configuration.
Strong candidates should have:
- Deep knowledge of commercial medical benefit design and administration, including deductibles, OOP maximums, copays, coinsurance, accumulators, benefit limits, exclusions and network-tier logic.
- Experience with ASO product configuration and employer-group customization, including understanding the substantially greater configurability required for self-funded business.
- Hands-on experience translating benefit/product designs into configuration specifications or detailed requirements for claims-adjudication platforms.
- Experience with at least one major payer core administration environment or equivalent configuration architecture; experience with platforms such as HealthRules, Facets, QNXT or similar would be valuable.
- Strong understanding of interactions among benefits, claims, eligibility, network, pharmacy, clinical programs, stop loss, billing and employer reporting.
- Experience developing configuration matrices, benefit specifications, business rules, requirements, use cases and acceptance criteria.
- Experience facilitating detailed cross-functional requirements/design workshops with Product, Operations and Technology.
- Ability to identify configuration implications and missing decisions rather than simply documenting what stakeholders tell them.
- Strong documentation discipline and ability to maintain traceability from product decision → business rule → configuration/requirement → acceptance criteria.
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