Medicare Operations Director at Blue Cross Blue Shield Association

Washington, District of Columbia, United States -

Full Time

Start Date

Immediate

Expiry Date

05 Jun, 26

Salary

180000.0

Posted On

07 Mar, 26

Experience

5 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Medicare Advantage Operations, Operational Leadership, Vendor Management, Regulatory Adherence, Continuous Improvement, Budgeting, KPIs, SOPs, Payment Integrity, Fraud Waste And Abuse Controls, System Implementations, Star Ratings Performance, Lean Six Sigma, Contract Management, Business Requirements, Change Management

Industry

Insurance

Description

Provide end-to-end operational leadership for the Medicare Advantage (MA) program, overseeing day-to-day operations, compliance, vendor management, and strategic execution across the member lifecycle. Drive operational excellence through metrics, governance, regulatory adherence, and continuous improvement while partnering closely with FEP leadership, Plans, IT, vendors, and CMS. Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development. Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls. Lead business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders. Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement. Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking. Manage vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS. Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives. Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff. Minimum 5-7 years of Medicare Advantage operational experience Experience with health plan administration systems and platforms. Experience with Federal Employee Program or federal health benefits programs, preferred Background in both operational and technical aspects of MA plan administration preferred Experience working with FACETS claims processing system to manage healthcare claims adjudication, benefits configuration, and member eligibility, ensuring accurate and timely claims processing and resolution. Experience leveraging AI technologies (machine learning, natural language processing, automation tools) to streamline operational processes and enhance customer experience, resulting in measurable improvements in efficiency, cost reduction, and customer satisfaction. Familiarity with Agile/Waterfall project methodologies Proficiency in Microsoft Office Suite, particularly Excel and Visio Experience with requirements management tools preferred Demonstrated experience managing vendor relationships, preferably with system integrators Proven track record writing business requirements and supporting system implementations Experience working in health plan operations or similar healthcare environment Comprehensive understanding of Medicare Advantage regulations, CMS requirements, and compliance standards (including Star Ratings, RADV, risk adjustment) Strong vendor management and contract oversight capabilities Excellent business analysis and requirements documentation skills Strategic thinking with ability to transition from tactical execution to long-term planning Proficiency in process improvement methodologies (Lean, Six Sigma) Strong project coordination and organizational skills with ability to manage ambiguity Exceptional written and verbal communication abilities Proven ability to influence without authority and build consensus Change management and organizational development capabilities Ability to manage multiple priorities in a fast-paced, dynamic environment Previous experience in a matrixed organizational structure preferred PMP, PGMP, CBAP, or similar professional certification preferred Knowledge of healthcare data standards (HIPAA, X12, HL7) preferred The posting range for this position is $141,000 to $180,000. #LI-Hybrid The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay. We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. If you are a current employee please apply directly through Workday. Begin your career at Blue Cross Blue Shield Association (BCBSA) by exploring currently opportunities and starting your application. It’s easy! After reviewing our open positions, apply to the roles that meet your requirements and ours too. You can keep track your progress in the selection process and review new postings too. Thanks for interest in joining Team BCBSA! At Blue Cross Blue Shield Association (BCBSA), we are a national association of 33 independent, community-based and locally operated Blue Cross Blue Shield companies and we are driven by purpose. Join the team who supports the nation's largest healthcare network, providing coverage to nearly one in three Americans as we relentlessly pursue affordable healthcare and ensure peace of mind for the people we serve. Be part of our storied history of innovation as we advance well-being and health equity. Experience a culture that is built on our core values, connection, work-life flexibility, well-being, and a commitment to our community. If you thrive at a company that values inclusivity, accountability, courage, teamwork, and respect, we're glad you found us!

Responsibilities

This role provides end-to-end operational leadership for the Medicare Advantage (MA) program, overseeing daily operations, compliance, vendor management, and strategic execution across the member lifecycle. Key duties include owning MA operational performance, ensuring compliant claims and payment operations, and driving strategic planning and process optimization.