Manager / Senior Manager Claims and Health Plan Operations

Texicare

14h•Hybrid

About The Position

We’re looking for passionate, mission-driven individuals to join us in creating a healthier and happier Texas. The Manager, Claims and Health Plan Operations is an experienced, results-driven operational leader responsible for the day-to-day management of core health plan operational functions, with an emphasis on claims processing performance, compliance, and member/provider experience. The ideal candidate will have a deep understanding of health plan claims administration, a proven track record of improving claims efficiency, and the ability to own the execution of strategic initiatives. In this role, you will play a critical role in ensuring the accuracy, compliance, and efficiency of our claims, enrollment/eligibility processes, new customer onboarding, stop loss operations and other related functions. This role serves as the primary operational lead for the daily relationship with the third-party administrator (TPA) and other operational vendors, ensuring service performance and issue resolution. The Senior Manager partners with business, technology, finance, compliance, and clinical leaders to translate strategic goals into operational plans and to implement process and system improvements that strengthen accuracy, efficiency, and scalability. This position reports to the Vice President, Health Plan Operations.

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.

Nice To Haves

Experience working at or in an oversight role of a Third-Party Administrator (TPA).
Experience designing and implementing payment integrity and cost-of-care initiatives
Advanced presentation, influencing, and building relationships skills.
Familiarity with seeking opportunities to improve and grow the business.
Experience in a start-up company environment.

Responsibilities

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.