Manager – Senior Manager, Claims and Health Plan Operations
Texicare
full-time
Posted on:
Location Type: Hybrid
Location: Austin • Texas • United States
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Job Level
About the role
- Manage the daily operations of health plan functions, including claims processing, enrollment/customer onboarding, eligibility, and provider contract management, including but not limited to direct management of the third-party administrator for these vended services.
- Serve as claims domain expert, supporting the business, technology, finance teams and other stakeholders to ensure cost efficient and compliant claims processing, payment, preparation and submission of regulatory deliverables, high-cost claims review and check run/provider payments.
- Lead operational implementation of new technology, systems, and products that enable claims and operational workflows; define requirements, test outcomes, support change readiness, and coordinate go-live stabilization (including vendor/platform transitions as applicable).
- Create and maintain payment and reimbursement policies, claims processes, procedures and workflows, and continuously monitor and evaluate performance of the claims operations against those standards.
- Coordinate across departments for proper alignment and effective administration of medical management requirements of hospital contracts; ensure that contract terminology, interpretation, and pricing issues are consistent with company cost-containment objectives.
- Accountable for ensuring Health Plan Operations metrics meet and/or exceed all compliance requirements, performance targets and service level agreements.
- Attract, retain, develop, and motivate a high-performance team by fostering an inclusive work environment, using a coaching approach, and communicating and exemplifying Texicare’s vision, values, and strategy.
Requirements
- Bachelor’s degree in business, Health Administration, or related field
- 6+ years of experience in Claims Administration and/or Health Plan Operations with substantive experience in small group, level funded products, self-funded and fully insured products
- Experience designing claims processes, designing claims workflows including stop loss, claims configuration, payments business rules development, and creation of operational claims policies and reimbursement policies
- Experience with enrollment/eligibility management; and complaints, appeals, and grievances management
- Ability to work with external organizations to deploy functionality in support of the product portfolio
- Experience managing and overseeing complex healthcare initiatives impacting multiple business areas
- Experience in strategic planning, organizational development, budget, and resource development
Benefits
- Automatic 4% employer contribution to retirement plan
- 401k plan with 100% match up to 6%
- Flexible time off for vacation, illness, etc.
- Nine paid holidays
- Day one health, Rx, vision, and dental insurance
- Life and disability insurance
- Flexible spending account
- Pet coverage and pet Rx discounts
- Free identity theft protection
- Free 2nd medical opinion service
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims processingenrollment managementeligibility managementclaims workflows designclaims configurationpayments business rules developmentoperational claims policiesreimbursement policieshealth plan operationsstrategic planning
Soft Skills
team developmentcoachingcommunicationleadershiporganizational developmentperformance monitoringstakeholder engagementchange managementinclusive work environmentmotivation
Certifications
Bachelor’s degree in businessBachelor’s degree in Health Administration