Pricing Configuration Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Lead the Configuration team within Provider Setup, transforming health plan contracts, medical policies, business rules, benefit designs, and provider pricing requirements into precise, scalable system configurations.

• Take ownership of team performance, configuration quality, delivery monitoring, and ongoing improvements that support claims adjudication, auto-adjudication, regulatory compliance, and integration across pricing, provider, benefits, enrollment, and claims operations.

• Oversee and nurture Configuration analysts; delegate tasks; set priorities and capacity plans; assess performance; offer training, coaching, technical development, succession planning, and career advancement opportunities.

• Conduct interviews and make recommendations for hiring decisions subject to the Director’s final approval.

• Manage 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.

• Communicate results, risks, and corrective measures to the Director.

• Supervise provider pricing and capitation arrangements, CMS fee schedules, benefit configuration, and workflow setups within TriZetto Facets and related tools.

• Coordinate the dependencies and transitions of claims, pricing, benefit, and workflow configurations across Provider Data Management, Practitioner Management, Network Management, enrollment, and NetworX/ITS functions.

• Collaborate with Claims, Claims Audit, Payment Integrity, Operations, Finance, Network Management, IT, and business stakeholders to convert plan documents, provider contracts, benefit designs, medical policies, business rules, network requirements, and regulatory mandates into testable system specifications.

• Design and implement configuration solutions for intricate provider pricing, capitation, and benefit arrangements.

• Lead troubleshooting and root cause analysis for claims processing errors, matching issues, cost shares, pricing discrepancies, coordination-of-benefits failures, and configuration-related pends.

• Execute corrective and preventive actions and ensure sustained resolution.

• Manage configuration promotion and change-control processes, which include requirements documentation, approval documentation, peer reviews, testing evidence, migrations, segregation of duties, post-production validation, and audit readiness.

• Coordinate configuration activities related to system upgrades, patches, releases, vendor-supported changes, impact assessments, testing, migration planning, and production validation.

• Act as the subject-matter expert for TriZetto Facets configuration strategy and propose enhancements that boost claims workflow efficiency and accurate auto-adjudication.

⛳️ Requirements

• 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.

• Minimum of 10 years of progressive experience in healthcare payer operations and technology, including significant exposure to claims, provider pricing, capitation, or benefit configuration utilizing TriZetto Facets or another payer technology platform.

• At least three years of direct management experience overseeing configuration analysts or similar healthcare payer operations or technology teams, with responsibilities including performance management, coaching, workload planning, and hiring.

• Extensive 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.

• Proven ability to employ SQL-based validation, claims data, operational metrics, and root cause analysis to test configurations and rectify defects.

• Familiarity with electronic data interchange transactions such as 837/835 and healthcare coding standards, including CPT, ICD-10, and HCPCS.

• Experience managing 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 in enhancing accurate and timely claims payment, auto-adjudication, service-level performance, configuration quality, and career development within a highly experienced team.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance.

• Retirement savings plan with employer matching.

• Opportunities for professional development and career advancement.

• Flexible work arrangements and a supportive work environment.