Pricing Configuration Lead - Claims & Auto-Adjudication

CareMore Health; California; On-site; USD 130,000 - 195,000; Full time

Job summary

CareMore Health in California seeks a Configuration Manager to lead the pricing configuration team, translating health plan contracts and pricing requirements into scalable system configuration. You will own performance and quality, coordinating with Network, Claims, IT and Finance to ensure accurate claims payment and timely provider setup.

The role requires 10+ years in payer operations, 3+ years of people management, and deep experience with TriZetto Facets and CMS scheduling.

Qualifications

• Bachelor’s degree in IT, healthcare administration, business or equivalent.
• 10+ years in healthcare payer operations/tech with claims, pricing or benefits config.
• 3+ years of people management leading configuration teams and hiring.
• Deep knowledge of claims configuration, pricing, CMS fee schedules and cost-share logic.
• SQL-based validation and root cause analysis to test configuration and resolve defects.
• Experience with 837/835 transactions and CPT/ICD-10/HCPCS coding.

Responsibilities

• Manages and develops configuration analysts; assigns work and sets priorities.
• Directs daily configuration operations, intake, prioritization and SLAs.
• Oversees provider pricing, capitation, CMS fee schedules, and workflows.
• Coordinates with Provider Data Management, Network and IT for specs and handoffs.
• Designs configuration solutions to boost auto-adjudication and reduce errors.
• Leads troubleshooting for claims processing issues and root-cause analyses.
• Manages change-control, migrations, testing and post-production validation.
• Plans upgrades, patches, releases and vendor-supported configuration changes.

Skills

Payer operations

Leadership

SQL validation

Root cause analysis

Claims adjudication

Education

Bachelor's degree in IT / Healthcare / Business

Tools

TriZetto Facets

Facets Configuration Utility

Job description

CareMore Health in California seeks a Configuration Manager to lead the pricing configuration team, translating health plan contracts and pricing requirements into scalable system configuration. You will own performance and quality, coordinating with Network, Claims, IT and Finance to ensure accurate claims payment and timely provider setup.

The role requires 10+ years in payer operations, 3+ years of people management, and deep experience with TriZetto Facets and CMS scheduling.