Health Plan Operations Specialist

Texicare Health Insurance Company; Town of Texas (WI); Remote; USD 60,000 - 85,000; Full time

Job summary

Texicare Health Insurance Company is seeking a dedicated Health Plan Operations Specialist to enhance operational effectiveness and support our mission of improving Texans' access to quality healthcare. The ideal candidate will have at least 2 years' experience in health plan operations, strong project management skills, and the ability to thrive in a collaborative environment. Responsibilities include claims analysis, workflow optimization, and maintaining compliance standards.

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

Qualifications

• At least 2 years' experience in health plan operations required.
• Strong attention to detail and project management skills essential.
• Experience working cross-functionally and communicating effectively.

Responsibilities

• Analyze claims and member benefit data to identify discrepancies.
• Collaborate with cross-functional teams to support operational improvements.
• Monitor and validate key performance indicators related to operations.

Skills

Attention to detail

Project management

Communication

Data analysis

Collaboration

Education

Bachelor's degree

Tools

Microsoft Excel

Tableau

Job description

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

We are seeking an experienced and detail-oriented Health Plan Operations Specialist to join our team. You will be responsible for supporting core operational functions as part of our Health Plan Operations team, including but not limited to, analyzing and resolving problems pertaining to claim payments, eligibility, provider fee schedule configuration, group implementation and system issues.

In addition to operations management, you will support the development, documentation and optimization of operational workflows and processes that are used by cross-functional teams across the organization. You will be collaborating with our Sales, Network, Product, Finance, Data Analytics, and Technology teams to align on handoffs, accountabilities, and workflow definitions. You will also support crucial member, provider, broker and employer escalation and issue management to ensure our stakeholders receive the highest level of service from Texicare.

We are looking for someone who will be proactive, will thrive in a cross-functional environment, and will be able to manage multiple tasks and projects simultaneously. You will report to our Director, Claims & Insurance Operations.

In this role, you will:

• Analyze claims, provider, and member benefit data to identify discrepancies, billing anomalies, and issues related to plan design, system configuration, or regulatory compliance.
• Research, respond to, and resolve service issues and escalations from members, providers, brokers, and employer groups in coordination with internal teams and external partners.
• Monitor and validate key performance indicators (KPIs) related to provider data accuracy, claims adjudication, and operational workflows.
• Deliver reports and actionable insights to internal stakeholders to inform operational strategy and improvements.
• Identify operational gaps and recurring issues; recommend and implement solutions to drive efficiency and improve service delivery.
• Support business planning and operational reporting activities by developing ad hoc analyses, dashboards, and performance summaries.
• Collaborate with cross-functional teams to support projects, new initiatives, and continuous improvement efforts across health plan operations.
• Maintain documentation and standard operating procedures (SOPs) to ensure consistency, transparency, and audit readiness.

To be successful in this role, you should have:

• At least 2 years’ experience in health plan operations or equivalent education, training, or experience is required. Candidates without prior health plan experience will not be a fit for this role.
• A bachelor’s degree or equivalent education, training, or experience.
• Strong attention to detail, particularly when reviewing member, provider, claims pricing, benefits and regulatory documents.
• Experience working cross-functionally with internal teams and managing external vendor relationships.
• Strong project management, organizational, and communication skills.
• Experience with data analysis, visualization, and manipulation.
• Proficiency in Microsoft Excel, with the ability to manage and analyze data effectively. Experience with Tableau would be a plus.
• Ability to manage multiple priorities and work effectively in a fast-paced environment.
• Ability to work remotely full-time in Texas with quarterly travel to corporate headquarters in Austin, TX.
• 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 opportunity employer.