Job Description Summary

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Manages the Pricing Configuration team responsible for translating provider contracts, reimbursement schedules, benefit requirements, and business rules into accurate claims adjudication system configurations. Oversees pricing and benefit configuration activities, fee schedule maintenance, configuration audits, and resolution of discrepancies affecting provider payments. Coordinates with Contracting, Claims, IT, and other operational teams to maintain configuration accuracy, support timely implementation of changes, and improve claims processing efficiency.

Manager, Pricing Configuration leads a team of professionals with accountability for operational results over a short-term horizon of up to six months. Decisions impact team output and short-term functional performance. This job plans and establishes team goals, manages headcount and resources within the team, coaches direct reports through performance cycles, and coordinates across teams to ensure consistent execution.

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How will you make an impact & Requirements

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KEY RESPONSIBILITIES

·       Manage and develop Pricing Configuration analysts, including assigning work, establishing priorities, monitoring performance, providing coaching and technical guidance, and supporting hiring and employee development activities.

·       Direct daily pricing and benefit configuration operations, including workload planning, capacity allocation, service-level monitoring, backlog management, and timely completion of configuration requests.

·       Oversee the setup, maintenance, and validation of provider reimbursement arrangements, contracted rates, capitation structures, CMS fee schedules, and benefit configurations within TriZetto Facets and related claims adjudication systems.

·       Coordinate with Network Contracting, Claims, Provider Data Management, Finance, and IT to translate contractual requirements, reimbursement methodologies, benefit designs, and business rules into accurate system configurations.

·       Establish and monitor configuration quality controls, including pre- and post-implementation audits, peer reviews, testing documentation, change records, and production validation to support accurate provider payments.

·       Lead investigation and resolution of configuration-related claims processing errors, pricing discrepancies, benefit calculation issues, and payment exceptions. Coordinate corrective actions and identify opportunities to reduce rework and increase accurate auto-adjudication.

·       Coordinate configuration activities for system upgrades, releases, regulatory updates, and implementation projects. Monitor operational risks, report performance results, and escalate material issues to the Director.

QUALIFICATIONS

·       Bachelor's degree in Information Technology, Healthcare Administration, Business, or a related field required; an equivalent combination of education and relevant healthcare payer operations experience may be considered.

·       At least 7 years of progressive experience in healthcare payer operations, claims adjudication, provider reimbursement, or pricing and benefit configuration, including at least 3 years of direct people-management experience.

·       Advanced knowledge of healthcare provider reimbursement methodologies, contracted pricing arrangements, capitation, CMS fee schedules, benefit configuration, cost-share calculations, and claims adjudication processes.

·       Experience configuring, maintaining, testing, and auditing reimbursement and benefit arrangements within TriZetto Facets or a comparable healthcare payer claims administration platform. Experience with the Facets Configuration Management Utility preferred.

·       Demonstrated experience with configuration quality assurance, change control, system implementations, release testing, production troubleshooting, and root cause analysis. Working knowledge of SQL-based validation, healthcare coding standards, and electronic claims transactions preferred.

·       Strong analytical, organizational, communication, and leadership skills, with demonstrated ability to manage competing priorities, develop technical employees, coordinate cross-functional work, and resolve complex operational issues.

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Compensation Range:

$130,159.00

to

$195,238.00

 

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.