Health Plan Program Manager SR or Technical Lead

Were seeking an experienced health plan professional with a strong background in benefit optimization healthcare data analysis vendor management and contracting. The ideal candidate will have hands-on experience working with or for health plans and be familiar with commercial and Medicare plans benefit contracts and claims dataand be proficient in tools like SQL and Power BI for analyzing and visualizing complex claims data. This role also requires an understanding of self-funded and fully insured contracts as well as the ability to interpret healthcare regulations and drive strategic improvements.

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.

The Health Plan Technical Lead is responsible for performing highly complex health care related research analysis and contracting and vendor management work. The incumbent will analyze health care related data to support benefit decision-making and plan optimization lead medical benefits procurement and contracting process for health care services monitor plan administrator services and performance to identify and resolve issues and provide technical expertise and coaching to staff supporting the medical plans. This position will proactively work with multiple vendors and consultants the Health Finance team Health staff and agency employees.

This vacancy will be filled at one of two levels - Health Plan Program Manager Senior or Health Plan Technical Lead. Selected applicant will be offered the position that most closely matches their education and experience.

Salary Range
Health Plan Program Manager Senior: $120000-$150000 Annually
Health Plan Technical Lead: $133110-$170000 Annually

This is a hybrid position at our Austin office.

WHAT YOU WILL DO:

Health Plan Program Manager Senior

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.

Health Plan Technical Lead

Technical Oversight
Serves as the lead technical expert to teams supporting the medical benefit plans.
Provides technical guidance to team members assess training needs of team members and arranges for or provides training coaching and technical assistance.
Recommends enhancements to existing tools and processes to improve efficiency accuracy and member outcomes.
Leads the development and implementation of data-driven strategies for medical contract performance analysis and benefit optimization
Establishes and enforces technical standards for reporting accuracy and contract performance metrics.
Conducts peer reviews of analyses and reconciliations used in medical contract evaluations.
Serves as the liaison between Health Finance Operations clinical experts and external consultants and vendors to ensure alignment on medical plan initiatives.
Supports other areas of Health in analyzing program data and developing key performance indicators and dashboards as needed

Research and Analysis on Contract Performance and Benefit Management
Reconciles financial performance guarantees relating to claim trends medical rebates and discounts and other financial measures.
Oversees the development of reports and dashboards from TRS data warehouse that support performance monitoring and decision-making.
Reviews medical claims utilization management and network pricing in support of plan performance monitoring.
Facilitates the interpretation of health care data from external sources including data from TRS health care consultants insurance companies or other industry resources.
Oversees quality assurance and and validate reports on health plan performance.

Health Care Services Procurement & Contract Management
Leads the development of procurement documents such as statements of work deliverables qualifications and evaluation criteria.
Conduct pre-bidding conferences and evaluates bidder proposals with respect to operational capabilities and financial terms.
Negotiates business and financial terms of contracts with vendors.
Finalizes contract documents in coordination with TRS Legal and Purchasing departments.

Program Administration
Monitors vendor performance in areas of cost trends service/process quality and delivery implementation of plan initiatives and contract compliance to assess penalties as needed.
Researches recommends and implements new cost efficient measures for program activities.
Works with clinicians to recommend benefit adjustments based on clinical evidence and cost.
Regularly communicates with vendors related to plan performance and initiatives claims and utilization provider network updates medical changes marketplace situations and trends.
Coordinates and oversees internal and external audits of contractors and resolves audit findings.
Present benefit coverage strategies to improve plan performance to leadership
Assists in the development of procedures to improve existing processes and in the implementation of new processes.
Trains and provides technical assistance to team members on relevant laws regulation policies procedures and processes.
Lead special projects task forces and committees as needed.
Represent department management at internal and external meetings as needed