$80K — $100K *
This position is responsible to identify, analyze, and implement changes in Medicaid benefits and ensuring benefit set-up aligns with Medicaid state plan requirements. Serve as subject matter expert for internal departments, participate in various workgroups and committees. Assist in development and maintenance of internal process for UCare decisions on Medicare and Medicaid coverage in absence of CMS or DHS guidance. Research, analyze, interpret, and communicate benefit and coverage information from regulators. Perform complex functions as necessary to respond to requests from stakeholders, and for business continuity purposes. Manage the Medicare Advantage Plan Benefit Package (PBP) completion and benefit filing process.
·Review Medicare and Medicaid benefit changes, operational improvement opportunities, and benefit payment processes or clarifications that require project management. Determine the size and scope of the change(s); assemble appropriate project team. Utilizing organization’s project management tools and guidelines, develop project plans including, as needed: timelines and deliverables; project documentation; communications plans; presentation to appropriate committees; and a successful close-out of each benefit change project.
·Assist Regulatory Materials Team on Medicare and Medicaid benefit and coverage questions, details and feedback specific to the Medicare Advantage Plan Benefit Package (PBP), Summary of Benefits and Evidence of Coverage/Member Handbook.
·Collaborate with Public Affairs, Government Relations Medicare/Medicaid Team Associate Director and Government Relations Federal Manager to research, interpret, and analyze impact of federal or state benefit and coverage changes.
·Serve as a research specialist regarding Medicare and Medicaid managed care benefits policy for alignment with fee-for-service benefits. Analyze and interpret regulatory and policy benefits from regulators (fee-for-service and managed care); respond to benefit and coverage questions; effectively communicate information to appropriate departments.
·Prepare for and file annual Medicare Advantage Plan Benefit Packages (PBP’s). This includes: downloading of PBP software; monitoring/reviewing and incorporating all CMS guidance concerning the PBP and Medicare Advantage benefit filing process; comprehensive testing of the PBP software; establishing plan structure in CMS’ Health Plan Management System (HPMS) to support product filings; coordinating, with Health Care Economics, the maintenance of the Medicare Advantage and MSHO benefit grids used for benefit filing documentation; providing feedback to CMS; coordinating with Strategy & Product Management on benefit description accuracy; coordinating PBP/bid document alignment for upload; and completing PBPs for upload via HPMS.
·Complete CMS requested or required Medicare Advantage benefit reviews.
·Participate as a member of the Bids and Benefits Workgroup (Medicare products), Configuration Requirements/Treatment Type Workgroup and UCare’s Product Teams (ad hoc).
·Lead assessment/implementation of supplemental benefits, collaborating with other Coverage Policy Team members and Product Managers.
·Maintain a tracking mechanism (SharePoint site) of regulatory information received and researched. Distribute CMS transmittals via U360.
·Annually review the department’s procedure for communicating to Medicare members and Associate Medical Director(s) National Coverage Determinations. Communicate to Associate Medical Director(s) and project manage these changes as needed.
·Other projects and duties as assigned.Education
Bachelor’s degree in Business Healthcare Administration or other relevant field; demonstrated experience may be considered in lieu of degree.
Five year’s work experience in managed care, including Medicare and Medicaid and/or Medicare managed care. Knowledge of clinical vocabulary. Experience in a clinical field such as nursing, or a clinically related public health field. Knowledge of Medicare Coverage Guidelines and listservs, CMS manuals, and DHS bulletins and manuals. Experience at a Medicare Administrative Contractor/carrier such as Noridian or Wisconsin Physicians Service Insurance Corporation (WPS) may substitute for managed care experience. Business process improvement or project management. Presentation experience. Knowledge of managed care coding and claims systems.
Experience managed care organization. Background in member benefits.
Valid through: 9/29/2020