Director I Medicare Operations

Director I Medicare Operations

Location:  This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our PulsePoint locations.

National Government Services is a proud member of Elevance Healths family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

The Director I Medicare Operations is responsible for directing multiple business function operations teams on Tier I contract with primary responsibility for Program Management and/or Medicare Integrity Operations.

How you will make an impact:

Responsible for directing multiple business function operations teams on Tier I contract with primary responsibility for Program Management and/or Medicare Integrity Operations.

Program Management includes but is not limited to: Claims, Grievance & Appeals, Administrative Law Judge (ALJ) appeals, Written Inquiries, Overpayment Recoveries, and Medicare Secondary Payer for National Government Services (NGS) a contractor for the Centers for Medicare and Medicaid Services.

Medicare Integrity Operations includes but is not limited to: Medical Policy/Review including any CMS funded demonstration projects, the analysis of data to review the impact of medical policy application as well as to ascertain adherence to the policies, Provider Outreach and Education, PSC Liaison activities, data mining & reporting, and identifying opportunities for improvement and consistency of decisions.

Responsible for Quality Assurance, response to Internal Audit results, Workforce Management and ensuring that all parties are in compliance with Federal laws and regulations for National Government Services (NGS) for Tier I contracts.

Directs the daily activities of the Quality Review staff in performing reviews of operational quality issues.

Manages the performance of compliance to determine the adequacy of the internal controls and identifies workflow efficiencies by using the Quality Assurance Surveillance Plan (QASP) used by CMS to evaluate performance on the contract.

Ensures deficiencies in compliance are identified and recommendations are prepared as necessary to strengthen the control environment.

Drives innovation throughout the assigned business function areas to reduce the overall costs associated with performing the CMS statement of Work requirements.

Strong Financial Acumen; ability to manage department financials to include: annual forecasting, monthly oversight, ability to adequately convey trends and resolve variances.

Ability to develop a 2-3 year operational strategy plan and manage oversight of plans.

Has frequent and regular contact with various representatives of CMS and peer contractor staff. Ability to meet with customer and deliver polished presentations when needed.

Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Travels to worksite and other locations as necessary.

Minimum Requirements:

Requires a BA /BS in a related field and minimum of 7 years professional/leadership experience with CMS, including strategic planning, project management, Medicare or related healthcare insurance or medical policy field, minimum of 3 years management experience; or any combination of education and experience, which would provide an equivalent background.

This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.

Preferred Skills, Capabilities, and Experience:

Understanding of technology and ability to partner with IT to create a roadmap for enhancements and automation, preferred.

Experience with managing operational workloads, productivity and planning forecasts and creating formalized plans to resolve issues, preferred.

Understanding of the Agile PI Planning Process, preferred.

Innovation and Change mindset; must have experience managing associates through change, preferred.

For candidates working in person or remotely in the below location(s), the salary range for this specific position is $117,200 to $210,960.

Locations: District of Columbia (Washington, DC); Maryland; New York.

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Companys sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success – for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.