Health Plan Program Manager Senior

Health Plan Program Manager Senior

We are 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. 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.

What You Will Do :

• Research and Data Analysis :
• 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.
• Vendor Management :
• 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.
• Procurement and Contracting :
• 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 and 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.
• Health Plan Management :
• 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.
• Performs related work as assigned.

What You Will Bring :