ACCOUNTABILITIES

• Act as a consultant and collaborate with the Medicare, Compliance and other business leaders
• Model and validate the impact of new, current products, and programmatic changes as well as work with the financial optimization workgroup to assess for cost savings and revenue opportunities
• Serves as the company’s research specialist regarding Medicare methodologies and policies
• Provides Medicare subject matter expertise and assist in the implementation of programmatic changes based on regulatory guidance (support and responds to all program changes and updates)
• Analyzes Medicare market trends, examines competitor benefits and understand new market opportunities through tools such as TEG and DEFT research reports
• Partner with operational departments including Claims, Call Center, Finance, Enrollment, Vendor Management, and Medical Management to design processes/procedures ensuring effective & efficient operations and to determine the impact of implementing Medicare relevant products
• Identify & integrate operational best practices, partnering with key departments to optimize processes across the organization such as benefits administration, marketing & communications, and customer experience
• Work closely with Compliance and Regulatory teams to confirm adherence to CMS regulations
• Partner with internal & external stakeholders on key strategic, regulatory & operational projects
• Partner with Risk Adjustment & Analytics teams to ensure complete & successful RAPS/EDPS submissions including enrollment reporting when needed
• Develop and monitor operational dashboards and KPI’s to ensure operational effectiveness & compliance
• Perform root cause analysis of identified issues, in partnership with other departments as necessary, to identify opportunities for improvement, and develop innovative solutions
• Develops summarized reporting for leadership executive team review utilizing aggregate data and information to assist decisions in the financial optimization work-group
• Monitors both CMS regulations, lists, server’s and other sources to identify existing payment practice and proposed changes
• Serves as the department’s project lead to drive changes as a result of regulatory changes, such as proposed and final Medicare regulations and Medicare Provider Manual updates
• Supports the business partners to accurately implement software updates that impact Medicare tools
• Assists in operationalizing strategic partnership by providing regulatory and programmatic support
• Responsible for requirements development, follow through and testing support on end-to-end implementation of new systems that impact Medicare line of business
• Participates in various work groups and committees to support product - growth initiatives and provides input into processes and workflows that support timely system update
• Attends state public hearings to gain insight on proposed regulatory changes
• Collaborates with stakeholder departments to financial size and estimate the impact of financially impactful changes to methodologies
• Conducts research on benefit and product enhancements and works with stakeholders on cost/benefit analysis considering the aggregate product and benefit changes for evaluation
• Validates Benefit Package entry into the CMS system
• Audit Coordination
• Leads assigned audits and works with cross-functional departments to gather and deliver the necessary data to fulfill all audit requirements; including managing tracking grids, scheduling resources, and providing regular progress update reports to management
• Provide oversight of plan & vendor operations as they relate to the Medicare line of business, aligning outcomes to strategic goals & requirements
• Responsible to assist with the annual Medicare Bid submission ensuring Plan Benefit accuracy while working with internal departments to create competitive product
• Lead vendor and internal implementations for updated medical benefits and any needed changes
• Oversee Medicare monitoring including reviewing daily, weekly, and monthly reporting program elections and progress, enrollment and CMS submissions for accuracy and reconciliation
• Co-Lead Annual Enrollment Period processes ensuring education and alignment with internal departments
• Oversee the accuracy of regulatory materials including the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC)
• Ensure successful & complete submission of Medicare Part C & D reporting
• Partner with Compliance team to develop & follow up on action plans to improve effectiveness as required
• Monitor reports to track operational effectiveness
• Ensure Medicare vendors adhere to Service Level Agreements
• Ad-hoc projects as assigned

Bachelor’s degree in a related field and a minimum of 5+ years’ of relevant experience, or the equivalent combination of training and experience, in a fast paced, managed healthcare environment is required

• Minimum of 5 years of experience and advanced knowledge of Medicare requirements, products, and bid pricing
• Deep understanding of the government standards and product development
• Demonstrated success working cross functionally managing complex initiatives and deliverables
• Demonstrated knowledge and solid understanding of Medicare
• Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve
• Flexible, highly motivated, self-starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision
• Strong analytical skills coupled with good communication skills, both oral and written, ability to interact well with others at all management levels
• Demonstrated proficiency using MS tools, including excel with an interest or skill set to leverage reporting tools for analytical purposes
• Strong organizational skills and strong internal customer/business partnership/service skills
• Strong background in working with technical teams to implement complex business requirements, subsequent testing, and workflow closure
• Valid driver’s license require

PURPOSE

Under the direction of the Director, the Medicare Program Development and Implementation Lead serves as the subject matter expert (SME) on Medicare programmatic regulations for HNE and will support the Director in ensuring operational effectiveness, efficiency & compliance across all functional areas. The Medicare Program Development and Implementation Lead will partner with operational teams to implement new products, benefits & regulatory requirements, assisting in product development, monitoring the market, and analyzing its trends to support Health New England’s growth initiatives. The Medicare Program Development and Implementation Lead acts as a consultant and collaborates with the Medicare, Compliance and other business leaders. The Medicare Program Development and Implementation Lead will model and validate the impact of new, current products, and programmatic changes as well as work with the financial optimization workgroup to assess for cost savings and revenue opportunities for HNE.

EDUCATION / EXPERIENCE / OTHER INFORMATION (INCLUDE ONLY THOSE THAT ARE SPECIFIC TO THE ROLE)

Bachelor’s degree in a related field and a minimum of 5+ years’ of relevant experience, or the equivalent combination of training and experience, in a fast paced, managed healthcare environment is required

• Minimum of 5 years of experience and advanced knowledge of Medicare requirements, products, and bid pricing
• Deep understanding of the government standards and product development
• Demonstrated success working cross functionally managing complex initiatives and deliverables
• Demonstrated knowledge and solid understanding of Medicare
• Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve
• Flexible, highly motivated, self-starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision
• Strong analytical skills coupled with good communication skills, both oral and written, ability to interact well with others at all management levels
• Demonstrated proficiency using MS tools, including excel with an interest or skill set to leverage reporting tools for analytical purposes
• Strong organizational skills and strong internal customer/business partnership/service skills
• Strong background in working with technical teams to implement complex business requirements, subsequent testing, and workflow closure
• Valid driver’s license required