Director, Claims Administration - The Health Plan

 
Position: Director, Claims Administration - The Health Plan

Job ID: 149554

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 Director of Claims Administration — someone who works well in a fast-paced manage care setting. In this position, you’ll oversee, plan, develop, implement, and maintain the claims administration functions and related processes of the organization. This role will be responsible for the integrity of the claim’s payment and adjudication processes.

 

Think you’ve got what it takes?



Responsibilities :

Job Duties & Responsibilities

 

  • Oversees the coordinated approach to administering health care benefits for children under the guidelines of a primary and secondary Pediatric HMO
  • Guarantees department adheres to all contractual obligations and statutory regulations
  • Ensures the delivery of cost-effective, community-based, and culturally sensitive health care through comprehensive contracting, medical management, and documenting/reporting
  • Develops approaches, policies, and programs for a Medicaid and CHIP HMO based integrated delivery system goals and objectives, and meets performance goals and measurements
  • Mentors and develops staff towards expanding job roles to meet the continuous challenges and changes in the health care environment
  • Supervises contracts and governmental regulations, including promoting the ability to respond effectively to innovative initiatives
  • Ensures that claims are processed accurately and timely for reimbursement to Health Plan Providers and members, and follows contracted fee schedules and covered benefits as specified in the member evidence of coverage


Qualifications:

Skills & Requirements

 

  • Bachelor’s degree
  • 5 years of managerial experience and 5 years of claims management and oversight experience


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