Manager Pricing Configuration

Job Description Summary

‎ 

The Configuration Manager leads the Configuration team within Provider Setup and is responsible for translating health plan contracts, medical policies, business rules, benefit designs, and provider pricing requirements into accurate, scalable system configuration.

The role owns team performance, configuration quality, delivery controls, and continuous improvement to support accurate claims adjudication, increased auto-adjudication, regulatory compliance, and effective integration across pricing, provider, benefits, enrollment, and claims functions. Reporting to the Provider Setup Director, the Manager works in close partnership with the Provider Data Management and Practitioner Management leaders, Network
Management, market teams in California, Arizona, and Nevada, and stakeholders across Claims, Operations, Finance, and IT. The role coordinates cross-team dependencies, resolves complex configuration issues, and supports reliable provider setup, claims payment, and health plan implementation operations.

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.

‎ 

How will you make an impact & Requirements

‎ 

Essential Responsibilities

• Manages and develops Configuration analysts; assigns work; establishes priorities and capacity plans; evaluates performance; and provides training, coaching, technical development, succession planning, and career-development opportunities. Leads interviews and recommends hiring decisions for the Director’s final approval.
• Directs 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. Reports results, risks, and corrective actions to the Director.
• Oversees the construction and maintenance of provider pricing and capitation arrangements, CMS fee schedules, benefit configuration, and workflow setups within TriZetto Facets and related tools.
• Oversees claims, pricing, benefit, and workflow configuration and coordinates dependencies and handoffs with Provider Data Management, Practitioner Management, Network Management, enrollment, and NetworX/ITS functions to support accurate and timely claims payment and provider setup. Partners with business stakeholders, Claims, Claims Audit, Payment Integrity, Operations, Finance, Network Management, and IT to translate plan documents, provider contracts, benefit designs, medical policies, business rules, network and division-of-financial-responsibility requirements, and regulatory requirements into testable system specifications.
• Designs and implements configuration solutions for complex provider pricing, capitation, and benefit arrangements to support accurate and timely claims payment, increase accurate auto-adjudication, and reduce manual pricing, pends, rework, and payment errors.
• Leads production troubleshooting and root cause analysis for claims processing errors, member and provider matching issues, cost shares, pricing discrepancies, coordination-of-benefits failures, and configuration-related pends. Implements corrective and preventive actions with Claims, Claims Audit, Payment Integrity,Provider Data Management, Finance, and IT and verifies sustained resolution.
• Manages configuration promotion and change-control processes, including the Facets Configuration Management Utility, requirements and approval documentation, peer review, testing evidence, configuration migrations, segregation of duties, post-production validation, and audit readiness.
• Coordinates Configuration activities for system upgrades, patches, releases, and vendor-supported changes, including impact assessment, testing, migration planning, and production validation. Partners with the Provider Data Management Manager and Practitioner Management Manager to resolveprovider-setup dependencies and escalates material risks to the Director.
• Serves as the subject-matter expert for TriZetto Facets configuration strategy, with primary accountability for configuration that supports accurate and timely claims payment. Recommends system configuration changes that improve claims workflow efficiency and increase accurate auto-adjudication, and partners with Claims Audit, Payment Integrity, and Claims leaders to identify root causes and close configuration-related gaps upstream.

Required Qualifications

• 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.
• At least 10 years of progressive healthcare payer operations and technology experience, including substantial experience with claims, provider pricing, capitation, or benefit configuration using TriZetto Facets or another payer technology platform.
• At least three years of direct people-management experience leading configuration analysts or comparable healthcare payer operations or technology teams, including responsibility for performance management, coaching, workload planning, and hiring.
• Deep 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.
• Demonstrated ability to use SQL-based validation, claims data, operational metrics, and root cause analysis to test configuration and resolve defects. Working knowledge of electronic data interchange transactions such as 837/835 and healthcare coding standards including CPT, ICD-10, and HCPCS.
• Experience leading configuration work through platform upgrades, patch applications, release testing, configuration migrations, production validation, and post-implementation stabilization.
  

Preferred Qualifications

Experience with TriZetto Facets, the Facets Configuration Management Utility,

Medicare Advantage, delegated-risk arrangements, benefits automation, claims- pricing tools, or workflow-management platforms. Demonstrated success improving accurate and timely claims payment, auto-adjudication, service-level performance, configuration quality, and career development within a highly experienced team.

‎ 

Compensation Range:

$108,466.00

to

$162,698.00

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.