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.
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Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
We are searching for a Manager of Business Systems Operations - Managed Care Configuration – someone who works well in a fast-paced setting. In this position, you’ll be responsible for assisting with the interpretation of federal, state, and other regulations and requirements related to Medicaid and Children’s Health Insurance Program (CHIP) benefits and reimbursement. This role will be primarily responsible for determining system configuration needs based on federal and state guidelines, as well as medical policy decisions.
Think you’ve got what it takes?
- Ensures benefit configuration, contract configuration, provider configuration, fee schedule updates, claims edits, rate/code updates, and prior authorization configuration are all performed efficiently, accurately, timely, and in compliance with all federal and state regulations
- Provides guidance and direction on the implementation of medical policy decisions as they relate to benefits and reimbursement
- Manages new configuration implementations and/or configuration changes that impact benefits and reimbursement
- Assures that the requirements for the implementations and/or changes are thoroughly documented, appropriate testing is completed, and sign-off is obtained as needed
- Develops, implements, and maintains a comprehensive documentation system/repository for business requirements, configuration change requests, and testing plans and results
- Remains current on Texas Medicaid Provider Procedures Manual (TMPPM), Uniform Managed Care Contract (UMCC), Uniform Managed Care Manual (UMCM), and other bodies of knowledge that impact Medicaid and CHIP benefits and reimbursement, and have a direct impact on medical policy decisions and potential system configuration changes
- Reviews, interprets, and provides direction on new and changes to existing federal and state regulations and requirements mandated by Health and Human Services Commission (HHSC), Texas Medicaid & Healthcare Partnership (TMHP), Texas Department of Insurance (TDI), and other governing bodies as they relate to benefits and reimbursement
- Partners closely with IS and other TCHP department leaders to review and assess new functionality/capabilities based on system upgrades; determine if they will optimize business processes, resolve business problems/issues, or will not add value; make a recommendation on whether to implement the new functionality/capabilities
- Ensures that policies/procedures, standard operating procedures, desk-level procedures, and/or guidelines adhere to all Medicaid and CHIP regulatory requirements as they relate to benefits and reimbursement and staff are adequately trained on them
- Continuously assesses, develops, and implements process improvement opportunities within benefits, contract, provider, and prior authorization configuration, as well as fee schedule and rate/code updates that create efficiencies, demonstrate cost/administrative savings, and overall enhanced stakeholder (member/provider/employee) satisfaction
- Develops, tracks, and reports performance/productivity metrics/targets
- Evaluates benchmarks/targets on a regular basis to ensure they are in alignment with industry standards
- H.S. Diploma or GED required
- Bachelor’s degree in healthcare administration, business administration, or related field is preferred
- 5 years experience with health insurance payor systems, configuration management, and/or information systems is required
- 4 years experience in management/leadership is preferred
- Strong knowledge of health plan functions, including, but not limited to benefit configuration, contract configuration, fee schedule updates, claims processing, member enrollment and eligibility, EDI transactions, and utilization management
- Knowledge of Texas Medicaid and CHIP products and the medical insurance industry
- Highly skilled and proficient in applying technical principles
- Demonstrated analytical, problem-solving, and research ability as evidenced by experience in the identification of business requirements and making subsequent recommendations for implementing appropriate configuration solutions to address business needs or problems
- Strong change management skills
- Excellent written and verbal communication skills
- Ability to demonstrate success in developing partnerships to achieve outcomes, interact with internal and external stakeholders at different levels, effectively manage competing priorities and meet all deadlines
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