Pricing Configuration Manager

🕒 Ontem

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $108.466 - $162.698 / ano

⏰ Tempo Integral

🟠 Sênior

🔴 Especialista

👔 Gerente

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CareMore Health

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

💼 Consultoria

🛡️ Seguros

📦 Logística

Consulting • Insurance • Logistics

A CareMore Health é uma organização de saúde integrada que oferece cuidados de saúde primários avançados e personalizados através de uma rede de clínicas e cerca de 14. 000 provedores em vários estados dos EUA. A empresa se concentra em cuidados preventivos e gestão de condições crônicas complexas, fazendo parcerias com planos de saúde, corretores e redes de provedores para coordenar o atendimento aos pacientes e aceitar uma variedade de planos de seguro. A CareMore enfatiza um atendimento compassivo e centrado no paciente, apoiando tanto pacientes individuais quanto parceiros institucionais para melhorar os resultados e reduzir o custo total dos cuidados.

Descrição

• Lead the Configuration team within Provider Setup and translate health plan contracts, medical policies, business rules, benefit designs, and provider pricing requirements into accurate, scalable system configuration • Own team performance, configuration quality, delivery controls, and continuous improvement supporting claims adjudication, auto-adjudication, regulatory compliance, and integration across pricing, provider, benefits, enrollment, and claims functions • Manage and develop Configuration analysts; assign work; establish priorities and capacity plans; evaluate performance; provide training, coaching, technical development, succession planning, and career-development opportunities • Lead interviews and recommend hiring decisions for the Director’s final approval • Direct daily Configuration operations, including work intake, prioritization, capacity allocation, service-level performance, quality controls, backlog management, cross-functional project teams, and large-scale platform or health plan implementations • Report results, risks, and corrective actions to the Director • Oversee provider pricing and capitation arrangements, CMS fee schedules, benefit configuration, and workflow setups within TriZetto Facets and related tools • Coordinate claims, pricing, benefit, and workflow configuration dependencies and handoffs across Provider Data Management, Practitioner Management, Network Management, enrollment, and NetworX/ITS functions • Partner with Claims, Claims Audit, Payment Integrity, Operations, Finance, Network Management, IT, and business stakeholders to translate plan documents, provider contracts, benefit designs, medical policies, business rules, network requirements, and regulatory requirements into testable system specifications • Design and implement configuration solutions for complex provider pricing, capitation, and benefit arrangements • Lead production troubleshooting and root cause analysis for claims processing errors, matching issues, cost shares, pricing discrepancies, coordination-of-benefits failures, and configuration-related pends • Implement corrective and preventive actions and verify sustained resolution • Manage configuration promotion and change-control processes, including requirements documentation, approval documentation, peer review, testing evidence, migrations, segregation of duties, post-production validation, and audit readiness • Coordinate configuration activities for system upgrades, patches, releases, vendor-supported changes, impact assessment, testing, migration planning, and production validation • Serve as the subject-matter expert for TriZetto Facets configuration strategy and recommend changes that improve claims workflow efficiency and accurate auto-adjudication

🎯 Requisitos

• Bachelor’s degree in Information Technology, Healthcare Administration, Business, or a related field, or an equivalent combination of education and relevant healthcare payer operations experience • At least 10 years of progressive healthcare payer operations and technology experience, including substantial experience with claims, provider pricing, capitation, or benefit configuration using TriZetto Facets or another payer technology platform • At least three years of direct people-management experience leading configuration analysts or comparable healthcare payer operations or technology teams, including responsibility for performance management, coaching, workload planning, and hiring • Deep knowledge of claims configuration and adjudication logic, provider pricing and capitation arrangements, CMS fee schedules, benefit configuration, cost-share logic, claims workflow dependencies, and accurate and timely claims payment • Demonstrated ability to use SQL-based validation, claims data, operational metrics, and root cause analysis to test configuration and resolve defects • Working knowledge of electronic data interchange transactions such as 837/835 and healthcare coding standards including CPT, ICD-10, and HCPCS • Experience leading configuration work through platform upgrades, patch applications, release testing, configuration migrations, production validation, and post-implementation stabilization • Preferred: Experience with TriZetto Facets, the Facets Configuration Management Utility, Medicare Advantage, delegated-risk arrangements, benefits automation, claims-pricing tools, or workflow-management platforms • Preferred: Demonstrated success improving accurate and timely claims payment, auto-adjudication, service-level performance, configuration quality, and career development within a highly experienced team

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