Health Plan Program Manager Senior
Health Plan Program Manager Senior
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Job Description
1900 Aldrich Street
Austin Texas 78723
United States
WHO WE ARE:
With the Health Division youll be joining a passionate team of self-motivated change agents united by our mission: driving to design the delivery of high-quality healthcare for nearly three-quarters of a million active and retired Texas public educators.
The healthcare industry is complex and were a team of problem-solvers who are up for the challenge. With a focus on innovation and collaboration to catalyze the market we spend nearly $4 billion annually on healthcare to make a difference in our members lives. With a career at TRS youll be empowered through a culture of continuous learning front-line decision-making coaching and mentorship to shape the future of our work while transforming healthcare delivery for 1 in 41 Texans.
The Health Plan Program Manager Senior is responsible for performing complex health plan management work to ensure the plan is running efficiently benefits are being administered appropriately and to promote the long-term stability of the health insurance plans. The incumbent will conduct and synthesize healthcare data analyses and research monitor and evaluate the work of plan administrators lead and develop procurement and contract documents and provide actionable insights for improvement. This position will proactively work with Health Finance team Health staff and agency employees.
WHAT YOU WILL DO:
Research and Data Analysis
Conducts in-depth research and analysis of health care data to evaluate plan performance identify trends and develop actionable insights.
Synthesizes data into clear and concise analyses to inform decision-making and drive improvements.
Utilizes data visualization tools and techniques to effectively present complex data to diverse audiences.
Develops and automates SQL queries in our internal data warehouse to extract claim data for use in analyses and dashboards.
Reviews reporting of health care data from external sources including from TRS health care consultants insurance companies or other industry resources.
Analyzes provider reimbursement levels high-cost claims costs by geographic area and place of service and claim accuracy.
Identifies enrollment and cost trends cost-saving opportunities and potential fraud waste and abuse.
Analyzes claim data to support invoice processing.
Vendor Management
Conducts regular assessments of vendor activities to evaluate performance based on good understanding of contracts and adherence to contractual obligations.
Reviews and validates vendor reports on health plan performance.
Reconciles financial guarantees relating to medical loss ratios claim trends pharmacy rebates and discounts and ROIs.
Directs the work of vendors and monitors their progress on enacting TRS initiatives and information requests.
Addresses and resolves non-compliance or subpar performance issues with vendors and escalates issues appropriately.
Leads meetings with vendors and manage agenda items.
Procurement and Contracting
Conducts market research to assess the products services and viability of companies that could potentially enhance TRS services.
Collaborates with internal stakeholders within the Health Purchasing and Legal & Compliance divisions as well as with consultants to develop technical requirements scopes of work evaluation criteria and procurement documents.
Acts as project manager to ensure procurement documents are produced timely and according to project workplans.
Negotiates contract renewal terms requirements and improvements.
Evaluates proposals from vendors and make recommendations.
Health Plan Management
Communicates with stakeholders related to plan performance and initiatives claims and utilization provider network updates pharmaceutical changes marketplace situations and trends.
Recommends and implements strategies to optimize benefit delivery plan performance cost containment and clinical outcomes.
Collaborates with internal and external auditors to conduct claim and vendor performance audits; track all audit findings through resolution.
Reviews legislative bills impacting the health plan and provide fiscal note analyses. Implement bills that become law.
Performs related work as assigned.
WHAT YOU WILL BRING:
Required Education
Bachelors degree from an accredited college or university in health information management health care administration public health statistics finance business or a closely related field.
High school diploma or equivalent and additional full-time experience in health plan administration health data and/or health financial analysis claim auditing or similarly related experience may be substituted on an equivalent year-for-year basis.
Required Experience
Five (5) years of full-time directly related progressively responsible experience in administration of a health insurance plan health insurance consulting claim auditing or similarly related experience.
Experience in analyzing and visualizing health care claims data.
A masters degree or doctoral degree in a directly related field may be substituted on an equivalent year-for-year basis.
Required Registration Certification or Licensure
CTCM Certification within 6 months of hire.
Preferred Qualifications
Advanced degree in actuary science finance mathematics statistics business health care administrations or closely related field.
Recent experience in health plan administration or consulting pharmacy benefits actuarial services business finance claim auditing procurement and contracting.
CEBS Certification
Knowledge of
Data analysis concepts and methods including education equivalent to at least statistics for business.
Health benefit claims processing Medicare coordination of benefits standard medical procedures and billing.
Health care claims data including CPT HCPCS DRG ICD-10 and NDC.
Health care related laws regulations policies and procedures.
Self-funded and fully insured group health benefit products and contracts including Medicare Advantage.
Provider networks contracts plan operations and systems.
Healthcare systems and clinical concepts..
Skill in
SQL to query data and other tools such as Power BI.
Researching compiling and analyzing complex data.
Managing projects including planning organizing and prioritizing work assignments to manage a high-volume workload in a fast-paced and changing environment.
Interpreting and applying complex laws regulations policies and procedures.
Completing detailed work with a high degree of accuracy.
Presentation of information to audiences of varying levels understanding.
Ability to
Meet frequent and multiple deadlines manage conflicting priorities and demands and adapt to changes in schedules and assignments.
Think critically analyze problems evaluate alternatives and proactively recommend effective solutions
Communicate effectively and maintain harmonious working relationships with co-workers agency staff vendors and other external contacts and to work collaboratively in a professional team environment.
Military Occupational Specialty (MOS) Codes:
Veterans Reservists or Guardsmen with experience in the Military Occupational Specialty ( ) along with the minimum qualifications listed above may meet the minimum requirements and are highly encouraged to apply. Please contact Talent Acquisition at with questions or for additional information.
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Required Experience:
Manager
Employment Type
Full Time
