Manager - Claims Administration

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 Manager, Medical 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?

Skills & Requirements

• Bachelor's degree HIGHLY PREFERRED
• Bachelor's degree with substitute for four (4) of the required years of experience
• 2 years of leadership experience (Preferred)
• Required H.S. Diploma or equivalent
• 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.
• Required 7 years Health Plan claims administration or related experience

• Completes timely performance appraisals for direct reports
• Plan, develop, organize and implement processes to ensure timely and accurate claims processing
• Review and implement Texas Department of Insurance regulations pertaining to HMOs
• Conducts appropriate investigations and follows-up on Provider and Member complaints
• Plan, develop, organize and implement processes to ensure claim adjustments, appeals and correspondence is completed timely and accurately
• Plan, develop organize and implement claim processing functions and processes
• Develop policies and procedures and for a Pediatric HMO which are based on our integrated delivery system goals and objectives and which meet the performance goals and measurements
• Review and implement HHSC statutory reporting requirements of Texas Medicaid
• Strives to achieve the goal of accreditation with commendation
• Mentor and develop Claims Processing 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