About Texicare

Founded in 2023 as a mission-driven health affiliate of Texas Mutual, Texicare was created by a group of seasoned healthcare professionals, and is headquartered in Austin, Texas. 

Texicare is committed to changing the healthcare landscape by providing small businesses with innovative solutions that increase access to easy-to-use, more affordable, quality health care for Texans and their families. Texicare’s vision is to transform the healthcare ecosystem for the better, helping to create a healthier and happier Texas.  Our healthcare plans were designed to be used, to remove barriers to care, to truly make a difference in people’s lives. 

We’re looking for passionate, mission-driven individuals to join us in creating a healthier and happier Texas.

About the role

The Director, Claim and Insurance Operations is an experienced and results-driven leader who will oversee our organization's claims processing and operations. The ideal candidate will have a deep understanding of health plan claims administration, a proven track record of improving claims efficiency and the ability to drive strategic initiatives. As the Director, Claim and Insurance Operations, you will play a critical role in ensuring the accuracy, compliance, and efficiency of our claims, utilization management and member experiences processes.

This role owns the day-to-day management of core health insurance operational functions and is the directly responsible individual for the daily relationship with the third-party administrator to support the success of the organization. This leader will also collaborate on the design, development of growth initiatives and own operational implementation of these initiatives while ensuring Compliance with any state and federal regulatory requirements and develops strategies to mitigate any issues or performance levels. You will report to the Vice President, Health Plan Operations.

In this role, you will:

• Oversee the daily operations of health plan functions, including claims processing, enrollment/case install, eligibility, provider contract management, grievances and appeals and member services, including but not limited to director oversight of the third-party administrator for any vended services.
• Serve as claims domain expert, supporting the business, technology, finance teams and other stakeholders to ensure cost efficient and compliant claims processing, payment, preparation and submission of regulatory deliverables, high-cost claims review and check run/provider payments.
• Own and manage the implementation of new technology, systems, and products that enable and support claims processing and other health plan operations, including the implementation of a new claims vendor, TPA or BPAAS solution.
• Responsible for creating and maintaining payment and reimbursement policies, claims processes, procedures and workflows, and continuously monitoring and evaluating performance of the claims operations against those standards. Works with Compliance and Operational Business Units to ensure Compliance with regulatory requirements.
• Design, build and operate an effective utilization management organization including authorization review, concurrent review and medical determination processes in collaboration with clinical leadership.
• Collaborate with clinical leaders to establish cost-containment objectives and goals for utilization management department; plan and implement system and procedural changes to achieve the objectives and goals; determine metrics to support and monitor the goals on an ongoing basis.
• Coordinate across departments for proper alignment and effective administration of medical management requirements of hospital contracts; ensure that contract terminology, interpretation, and pricing issues are consistent with company cost-containment objectives.
• Accountable for ensuring Health Plan Operations metrics meet and/or exceed all compliance requirements, performance targets and service level agreements.
• Attracts, retains, develops, and motivates a high-performance team by fostering an inclusive work environment, suing a coaching, approach, and communicating and exemplifying Texicare's vision, values, and strategy.
• Identify technology, automation and artificial intelligence applications for health plan back-office functions for improved scalability, quality and speed to market.

To be successful in this role, you should have:

• Bachelor’s degree in business, health administration, a related field.
• 7-10 years of experience in Claims Administration or Health Plan Operations.
• Five or more years of experience designing claims processes, designing claims workflows, claims configuration, payments business rules development, and creation of operational claims policies and reimbursement policies.
• Experience with utilization management, prior authorizations and associated processes that support efficient claim adjudication.
• Experience with complaints, appeals, and grievances tracking to resolution.
• Ability to work with external organizations to deploy functionality in support of the product portfolio
• Experience managing and overseeing complex healthcare initiatives impacting multiple business areas.
• Experience in strategic planning, organizational development budget, and resource development.

Preferred qualifications:

• Experience working at or in an oversight role of a Third-Party Administrator (TPA).
• Demonstrated stop loss administration experience for various product offerings.
• Experience in small group, level funded products, self funded and fully insured products.
• Advanced presentation, influencing, and building relationships skills.
• Familiar with seeking opportunities to improve and grow the business.
• Experience in a start-up company environment.

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 Employment Opportunity employer.