Senior Pricing Configuration Lead, Payer Operations

CareMore Health Management Services, LLC; California; Hybrid; 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. You will translate health plan contracts, medical policies, and provider pricing into scalable configurations, ensuring accurate claims adjudication and regulatory compliance.

You will collaborate with Clinical, Network, Finance, IT, and market leaders across California, Arizona, and Nevada to align configurations with business goals, improve auto-adjudication, and

Qualifications

• Bachelor’s degree in IT, Healthcare Administration, Business, or related field, or equivalent combination of education and healthcare payer ops experience.
• 10+ years healthcare payer ops and technology experience including claims, pricing, capitation, or benefit configuration with TriZetto Facets or similar.
• 3+ years direct people-management experience leading configuration analysts or similar teams.
• Deep knowledge of claims configuration and adjudication logic, provider pricing and capitation, CMS fee schedules, benefit configuration, and cost-share logic.
• Experience with SQL-based validation and 837/835 and CPT/ICD-10/HCPCS coding standards.

Responsibilities

• Manage Configuration analysts; assign work; establish priorities; conduct training and career development.
• Direct daily Configuration operations including intake, prioritization, and SLA performance; monitor quality and backlog.
• Coordinate with Provider Data Management, Network Management, IT, and Claims teams to ensure timely claims payment and provider setup.
• Oversee provider pricing, capitation arrangements, CMS schedules, and workflow setups in TriZetto Facets; ensure change-control and audits.

Skills

People management

Claims configuration

Process improvement

Root cause analysis

Education

Bachelor’s degree in IT

Equivalent healthcare experience

Tools

TriZetto Facets

Facets Configuration Utility

SQL tooling

Job description

CareMore Health Management Services, LLC is seeking a Configuration Manager to lead the configuration team within Provider Setup. You will translate health plan contracts, medical policies, and provider pricing into scalable configurations, ensuring accurate claims adjudication and regulatory compliance.

You will collaborate with Clinical, Network, Finance, IT, and market leaders across California, Arizona, and Nevada to align configurations with business goals, improve auto-adjudication, and