Director, Claims Administration Jobs

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 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org .

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.

Summary:

We are searching for a Director of Claims Administration - someone who works well in a fast-paced 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?

Job Duties & Responsibilities

• 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
• Supervises contracts and governmental regulations, including promoting the ability to respond effectively to innovative initiatives
• Guarantees department adheres to all contractual obligations and statutory regulations
• Oversees the coordinated approach to administering health care benefits for children under the guidelines of a primary and secondary Pediatric HMO
• Mentors and develops staff towards expanding job roles to meet the continuous challenges and changes in the health care environment
• 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

Skills & Requirements

• Bachelor's degree
• Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children's, unless approved for a medical or religious exemption.
• 5 years of managerial experience and 5 years of claims management and oversight experience