Director, Medicare Operations

Location: Hartford, CT
Company: CVS Health
Industry: IT
Job Type: Full Time
Posted: 4 days ago

In support of the Chief Medicare Officer, the Director Medicare (MDCR) Operations is responsible for ensuring that the local Medicare business is compliantly and effectively operating in the market. As such, the Director of Medicare Operations supports MAPD and SNP initiatives and implements and oversees activities and programs across the market to achieve earnings and growth objectives.

Additional Responsibilities as a Director Medicare (MDCR) Operations Include:

- Direct operational functions of Medicare products across a market as directed by the Chief Medicare Officer (acting as Chief Operating Officer)
- Responsible for AEP operational readiness including the education and training of Sales team, telesales and customer service teams
- Develops recommendations for Service Area Expansion/SAR's/Product terms
- Ensures that market Medicare network is adequate and optimized for customer marketability and works closely with the network team to support and ensure provider data accuracy
- Responsible for all operational aspects of Joint Venture partnerships
- Provides operational support for market management of plan sponsors, members and network providers

Participates in various committees to represent the Medicare department including NCQA, Internal Research, UM, QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, migration, etc.
- Has shared responsibility for all CMS, Bid and application activities
- Serves in a strategic capacity in the bid process as it relates to product and benefit design, competitive analysis, membership modeling, and Contract/PBP strategy
- Maintains awareness of trends and developments in Medicare and managed health care organizations
- Uses competitive intelligence to guide, consult and drive product implementation and strategic focus for Medicare Part D and Medicare Advantage
- In partnership with the Product organization, responsible for the oversight and execution, at the local market level, of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, group set up
- Develops Sales and Membership model in conjunction with CMO and Enterprise; accountable to ensure that all customer and broker facing material is accurate and compliant

Responsible for Member Retention and member experience initiatives.

- Manages Member Retention Specialist(s)
- Leads member retention activities, including development of outreach material, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues
- Develops and implements business strategies to provide accurate and proactive customer service to members, plan sponsors and brokers

Maintains current knowledge of State and Federal regulations.

- Monitors sales and marketing activities to assure adherence to Federal and State regulations
- Coordinates strategies and recommends policy positions with senior management regarding legislative issues and regulatory with a key support function in program and project management in support of Medicare Advantage and Medicare Part D, including Stars, Revenue Management, Quality and Network concerns

Represents Chief Medicare Officer in strategic and leadership meetings as needed.

- In partnership with Operations Integrity and at the direction of the Chief Medicare Officer, may facilitate internal and external Medicare audit activity including CMS and operations integrity audits. Coordinates file pulls, data requests, universe development and supporting documentation
- May, depending on local market needs, develop market-based risk adjustment strategies and drive execution of critical revenue related activities such as medical record capture and in-home assessments
- Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions, including employment, termination, performance reviews, salary reviews and disciplinary actions

Required Qualifications

- Minimum 5 years of health care business experience

Preferred Qualifications

- Medicare operational experience highly desired
- Ability and experience working effectively cross-functionally - Leadership and Supervisory experience
- Excellent written and verbal communication skills


- Bachelors' degree from an accredited college or equivalent work experience is required

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