Director of Claims Administration - TC Health Plan

 
Position: Director of Claims Administration - TC Health Plan

Job ID: 138136

Location: US-TX-Houston

Department: Administration-TC Health Plan

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Director, Claims Administration - someone who works well in a fast-paced hospital setting. In this position, you’ll oversee, plan, develop, implement and maintain Claims Administration functions and related processes. This position will have key responsibility for the integrity of the claims payment and adjudication process. This position will be responsible for ensuring that claims are processed accurately and timely for reimbursement to the Health Plan Providers and members, in accordance with contracted fee schedules and covered benefits as specified in the member evidence of coverage. The Health Plan processes approximately 160,000 claims per month representing approximately $23 million dollars paid per month.

 

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Responsibilities :

  • Plan, develop, organize, direct and implement a coordinated approach to administering health care benefits for children under the guidelines of a primary and secondary Pediatric HMO which responds to and meets all contractual obligations and statutory regulations
  • Ensure the delivery of cost-effective, community-based and culturally sensitive health care through comprehensive contracting; medical management; documenting/reporting; and outreach and education, with continuous quality improvement oversight
  • Develop approaches, policies and programs for a Medicaid & CHIP HMO which are based on the integrated delivery system goals and objectives and which meet the Health Plan performance goals and measurements
  • Mentor and develop Health Plan staff toward expansion of job roles in order to meet the continuous challenges and changes of the health care environment, contracts and governmental regulations, including promoting the ability to respond effectively to innovative initiatives
  • Oversee, plan, develop, implement and maintain the Claims Administration functions and related processes of the Health Plan while ensuring 1) the integrity of the claims payment and adjudication process and 2) claims are processed accurately and timely for reimbursement to the Health Plan Providers and members, in accordance with contracted fee schedules and covered benefits as specified in the member evidence of coverage


Qualifications:

  • Business degree from an accredited university.
  • A minimum of five (5) years of managerial experience
  • A minimum of five (5) years of claims management and oversight experience
  • Knowledge of Texas Department of Insurance regulations pertaining to HMOs 
  • Knowledge of statutory reporting requirements of HMOs
  • Understanding of Medicaid Allowable rules and other CPT, RBRVS coding rules that relate to the administration of payment on HCFA and UB forms
  • Knowledge of claims processing requirements and general principles
  • Knowledge of systems implementation and maintenance
  • Managerial skills
  • Process flow development skills
  • Organizational skills


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