Health Plan Program Manager Senior

Teacher Retirement System of Texas•Austin, TX

65d•Onsite

About The Position

With the Health Division, you'll be joining a passionate team of self-motivated change agents united by our mission: driving to design the delivery of high-quality healthcare for nearly three-quarters of a million active and retired Texas public educators. The healthcare industry is complex and we're a team of problem-solvers who are up for the challenge. With a focus on innovation and collaboration to catalyze the market, we spend nearly $4 billion annually on healthcare to make a difference in our members' lives. With a career at TRS, you'll be empowered through a culture of continuous learning, front-line decision-making, coaching and mentorship to shape the future of our work, while transforming healthcare delivery for 1 in 41 Texans. We're seeking an experienced health plan professional with a strong background in benefit optimization, healthcare data analysis, vendor management and contracting. The ideal candidate will have hands-on experience working with or for health plans and be familiar with commercial and Medicare plans, benefit contracts, and claims data-and be proficient in tools like SQL and Power BI for analyzing and visualizing complex claims data. This role also requires an understanding of self-funded and fully insured contracts, as well as the ability to interpret healthcare regulations and drive strategic improvements. The Health Plan Program Manager Senior is responsible for performing complex health plan management work to ensure the plan is running efficiently, benefits are being administered appropriately, and to promote the long-term stability of the health insurance plans. The incumbent will conduct and synthesize healthcare data analyses and research, monitor and evaluate the work of plan administrators, lead and develop procurement and contract documents, and provide actionable insights for improvement. This position will proactively work with Health Finance team, Health staff and agency employees. This is an onsite position at our Austin office, with the opportunity to work from home one day a week based on business needs.

Requirements

Bachelor's degree from an accredited college or university in health information management, health care administration, public health, statistics, finance, business or a closely related field.
High school diploma or equivalent and additional full-time experience in health plan administration, health data and/or health financial analysis, claim auditing or similarly related experience may be substituted on an equivalent year-for-year basis.
Five (5) years of full-time directly related, progressively responsible experience in administration of a health insurance plan, health insurance consulting, claim auditing, or similarly related experience.
Experience in analyzing and visualizing health care claims data.
A master's degree or doctoral degree in a directly related field may be substituted on an equivalent year-for-year basis.
CTCM Certification within 6 months of hire.
Data analysis concepts and methods, including education equivalent to at least statistics for business.
Health benefit claims processing, Medicare, coordination of benefits, standard medical procedures, and billing.
Health care claims data including CPT, HCPCS, DRG, ICD-10, and NDC.
Health care related laws, regulations, policies and procedures.
Self-funded and fully insured group health benefit products and contracts, including Medicare Advantage.
Provider networks, contracts, plan operations and systems.
Healthcare systems and clinical concepts. .
SQL to query data and other tools such as Power BI.
Researching, compiling and analyzing complex data.
Managing projects, including planning, organizing, and prioritizing work assignments to manage a high-volume workload in a fast-paced and changing environment.
Interpreting and applying complex laws, regulations, policies, and procedures.
Completing detailed work with a high degree of accuracy.
Presentation of information to audiences of varying levels understanding.
Meet frequent and multiple deadlines, manage conflicting priorities and demands, and adapt to changes in schedules and assignments.
Think critically, analyze problems, evaluate alternatives, and proactively recommend effective solutions
Communicate effectively and maintain harmonious working relationships with co-workers, agency staff, vendors and other external contacts and to work collaboratively in a professional team environment.

Nice To Haves

Advanced degree in actuary science, finance, mathematics, statistics, business, health care administrations, or closely related field.
Recent experience in health plan administration or consulting, pharmacy benefits, actuarial services, business finance, claim auditing, procurement and contracting.
CEBS Certification

Responsibilities

Conducts in-depth research and analysis of health care data to evaluate plan performance, identify trends, and develop actionable insights.
Synthesizes data into clear and concise analyses to inform decision-making and drive improvements.
Utilizes data visualization tools and techniques to effectively present complex data to diverse audiences.
Develops and automates SQL queries in our internal data warehouse to extract claim data for use in analyses and dashboards.
Reviews reporting of health care data from external sources including from TRS' health care consultants, insurance companies, or other industry resources.
Analyzes provider reimbursement levels, high-cost claims, costs by geographic area and place of service, and claim accuracy.
Identifies enrollment and cost trends, cost-saving opportunities, and potential fraud, waste, and abuse.
Analyzes claim data to support invoice processing.
Conducts regular assessments of vendor activities to evaluate performance based on good understanding of contracts and adherence to contractual obligations.
Reviews and validates vendor reports on health plan performance.
Reconciles financial guarantees relating to medical loss ratios, claim trends, pharmacy rebates and discounts, and ROIs.
Directs the work of vendors and monitors their progress on enacting TRS initiatives and information requests.
Addresses and resolves non-compliance or subpar performance issues with vendors and escalates issues appropriately.
Leads meetings with vendors and manage agenda items.
Conducts market research to assess the products, services, and viability of companies that could potentially enhance TRS' services.
Collaborates with internal stakeholders within the Health, Purchasing, and Legal & Compliance divisions, as well as with consultants to develop technical requirements, scopes of work, evaluation criteria, and procurement documents.
Acts as project manager to ensure procurement documents are produced timely and according to project workplans.
Negotiates contract renewal terms, requirements, and improvements.
Evaluates proposals from vendors and make recommendations.
Communicates with stakeholders related to plan performance and initiatives, claims and utilization, provider network updates, pharmaceutical changes, marketplace situations and trends.
Recommends and implements strategies to optimize benefit delivery, plan performance, cost containment, and clinical outcomes.
Collaborates with internal and external auditors to conduct claim and vendor performance audits; track all audit findings through resolution.
Reviews legislative bills impacting the health plan and provide fiscal note analyses. Implement bills that become law.
Performs related work as assigned.