Manager, Pricing Configuration

CareMore Health Management Services, LLC; San Francisco (CA); On-site; USD 130,000 - 195,000; Full time

Job summary

CareMore Health Management Services, LLC is seeking a Configuration Manager to lead the Configuration team within Provider Setup. The role translates health plan contracts, policies, and pricing into scalable system configurations to support accurate claims adjudication and regulatory compliance.

You will oversee pricing, benefit configuration, and workflow setups in TriZetto Facets, partnering with Data Management, Network Management, and IT to ensure timely claims payment and provider setup

Qualifications

• Bachelor’s degree in Information Technology, Healthcare Administration, Business, or a related field, or equivalent experience.
• 10+ years in healthcare payer operations/technology focusing on claims, pricing, capitation, or benefit configuration.
• 3+ years of direct people-management leading configuration analysts or similar teams.
• Deep knowledge of claims configuration and adjudication logic, provider pricing, CMS schedules, and benefit configuration.
• Experience with SQL-based validation and ROI-focused analytics for configuration defects.
• Experience with platform upgrades, patches, and post-implementation stabilization.

Responsibilities

• Manages and develops Configuration analysts; assigns work; establishes priorities and capacity plans; evaluates performance; and provides coaching and career development.
• Directs daily configuration operations, including intake, prioritization, capacity, SLAs, quality controls, backlog, and large-scale implementations.
• Oversees pricing, capitation, CMS schedules, and benefit configuration within TriZetto Facets and related tools.
• Coordinates dependencies with Provider Data Management, Practitioner Management, Network Management, enrollment, and IT to ensure timely claims payment and provider setup.
• Designs configuration solutions to improve accuracy of auto-adjudication and reduce errors.
• Leads root-cause analysis for processing errors and implements corrective actions across multiple teams.
• Manages change-control, migrations, and post-production validation; ensures audit readiness.
• Plans system upgrades/patches/releases and coordinates vendor changes.
• Serves as SME for TriZetto Facets configuration strategy and advocates for workflow efficiency.

Skills

Configuration management

Leadership

SQL validation

Claims configuration

Provider pricing

CMS fee schedules

TriZetto Facets

Stakeholder collaboration

Education

Bachelor’s degree in IT/Healthcare or related field

Tools

TriZetto Facets

Facets Configuration Management Utility

EDI knowledge (837/835)

Job description

Job Description SummaryThe 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, NetworkManagement, 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 & RequirementsEssential ResponsibilitiesManages 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 QualificationsBachelor’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 QualificationsExperience 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:$130,159.00to$195,238.00The 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.