Mgr of Claims Administration - The Health Plan

 
Position: Mgr of Claims Administration - The Health Plan

Job ID: 148667

Location: US-TX-Bellaire

Department: Claims - Administration

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a -5p Monday - Friday

About Texas Children's Hospital

The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.  We are an Integrated Community System providing holistic care that empowers families to live healthier lives.  Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.   To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

We are searching for a Manager for Claims Administration - someone who works well in a fast-paced managed care setting. In this position, you’ll plan, develop and implement claims processing functions and related processes for the Claims Administration Department. You’ll have key responsibility for the integrity of the claims payment and adjudication process. Additionally, you’ll 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.

 

Think you’ve got what it takes?



Responsibilities :

  • Plan, develop, organize and implement processes to ensure timely and accurate claims processing
  • Plan, develop, organize and implement processes to ensure claim adjustments, appeals and correspondence is completed timely and accurately
  • Develop policies and procedures
  • Mentor and develop staff toward expansion of job roles in order to meet the continuous challenges and changes of the healthcare environment, contracts and governmental regulations, including promoting the ability to respond effectively to innovative initiatives
  • Plan, develop organize and implement claim processing functions and processes
  • Complete timely performance appraisals for direct reports
  • Assure new staff attends hospital/departmental orientation within 30 days of employment
  • Develop and modify job descriptions as necessary
  • Conduct appropriate investigations and follow-up on provider and member complaints
  • Write, review, and maintain policies and procedures in areas such as strategies sourcing, competitive procurements, contract processing, negotiations, vendor management, contract pricing retention, and compliance
  • Represent the department at internal and external meetings, as well as deliver presentations to all entities of the hospital, including the department manager, assistant director, director, VP, and executive council when required


Qualifications:

  • High school diploma or GED
  • A minimum of seven (7) years of health plan claims administration or related experience
  • Bachelor's degree may be substituted for four (4) years of experience


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