Manager / Senior Manager Claims and Health Plan Operations at Texicare

, Texas, United States -

Full Time

Start Date

Immediate

Expiry Date

10 Jun, 26

Salary

0.0

Posted On

12 Mar, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Claims Processing, Health Plan Operations, Compliance, Member Experience, Provider Experience, Claims Administration, Efficiency Improvement, Strategic Initiatives Execution, Enrollment/Eligibility Management, Stop Loss Operations, Vendor Management, Process Improvement, System Improvements, Contract Management, Team Leadership, Change Readiness

Industry

Insurance

Description

Position Summary 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. Essential Job Functions In this role, you will: 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. To be successful in this role, you must have: 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. It would be great if you have: 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. 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 Location Texicare offers a flex-hybrid environment centered around collaboration and connection. All employees must reside in Texas. Team members living in the Austin area are expected to work from our office at least two days per week. Those based outside the greater Austin area may work remotely within Texas, with occasional travel to Austin as needed. Texicare is an equal opportunity employer.

Responsibilities

This role manages the daily operations of core health plan functions, including claims processing, enrollment, and eligibility, while serving as the primary operational lead for vendor relationships, particularly the third-party administrator (TPA). The manager also acts as the claims domain expert, supporting various teams to ensure cost-efficient and compliant claims processing and regulatory deliverable preparation.