Texicare

Compensation

Full Description

About the role We are seeking an experienced and detail-oriented Health Plan Operations Specialist to join our team. You will be responsible for supporting core operational functions as part of our Health Plan Operations team, including but not limited to, analyzing and resolving problems pertaining to claim payments, eligibility, provider fee schedule configuration, group implementation and system issues. In addition to operations management, you will support the development, documentation and optimization of operational workflows and processes that are used by cross-functional teams across the organization. You will be collaborating with our Sales, Network, Product, Finance, Data Analytics, and Technology teams to align on handoffs, accountabilities, and workflow definitions. You will also support crucial member, provider, broker and employer escalation and issue management to ensure our stakeholders receive the highest level of service from Texicare. We are looking for someone who will be proactive, will thrive in a cross-functional environment, and will be able to manage multiple tasks and projects simultaneously. You will report to our Director, Claims & Insurance Operations. In this role, you will: Analyze claims, provider, and member benefit data to identify discrepancies, billing anomalies, and issues related to plan design, system configuration, or regulatory compliance. Research, respond to, and resolve service issues and escalations from members, providers, brokers, and employer groups in coordination with internal teams and external partners. Monitor and validate key performance indicators (KPIs) related to provider data accuracy, claims adjudication, and operational workflows. Deliver reports and actionable insights to internal stakeholders to inform operational strategy and improvements. Identify operational gaps and recurring issues; recommend and implement solutions to drive efficiency and improve service delivery. Support business planning and operational reporting activities by developing ad hoc analyses, dashboards, and performance summaries. Collaborate with cross-functional teams to support projects, new initiatives, and continuous improvement efforts across health plan operations. Maintain documentation and standard operating procedures (SOPs) to ensure consistency, transparency, and audit readiness. To be successful in this role, you should have: At least 2 years’ experience in health plan operations or equivalent education, training, or experience is required. Candidates without prior health plan experience will not be a fit for this role. A bachelor’s degree or equivalent education, training, or experience. Strong attention to detail, particularly when reviewing member, provider, claims pricing, benefits and regulatory documents. Experience working cross-functionally with internal teams and managing external vendor relationships. Strong project management, organizational, and communication skills. Experience with data analysis, visualization, and manipulation. Proficiency in Microsoft Excel, with the ability to manage and analyze data effectively. Experience with Tableau would be a plus. Ability to manage multiple priorities and work effectively in a fast-paced environment. Ability to work remotely full-time in Texas with quarterly travel to corporate headquarters in Austin, TX. Benefits Automatic 4% employer contribution to retirement plan 401k plan with 100% match up to 6% Flexible time off for vacation, illness, etc. Nine paid holidays Day one health, Rx, vision, and dental insurance Life and disability insurance Flexible spending account Pet coverage and pet Rx discounts Free identity theft protection Free 2nd medical opinion service Texicare is an equal opportunity employer.