Manages the claims operations for Medicare Part D plans. Provides the technical and leadership skills that ensure successful Part D claims operations and program compliance. Makes business decisions that have impacts on members, providers, Part D plans and the company. Requires knowledge of Medicare Part D plan rules with experience in claims processing oversight. Works with internal partners, ensures established rules, policies and procedures are implemented to ensure successful, efficient, auditable Med D operations in compliance with CMS (Centers for Medicare and Medicaid Services) requirements.
- Develops strategic, operational and tactical business plans to achieve desired business goals for responsible units.
- Reviews and directs service operation performance to meet or exceed business goals.
- Provides leadership to the team providing claims oversight including oversight of rejected claims, approved claims, grievances, appeals, paper claims.
- Builds and maintains collaborative relationships and alliances with internal and external customers to achieve business goals.
- Fosters confidence and trust with client base.
- Identifies and implements process improvements on multiple systems or units within the business unit.
- Recruits, attracts, develops, motivates and manages a high caliber of talent. Maintains a positive work environment that supports self-directed teams; provides a structure to optimize the experience, skill, knowledge and capability of the teams.
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
7+ years in service industry/operations with progressive supervisory responsibilities, Experience with Medicare Part D program, Understanding of CMS guidance applicable to the Medicare Part D program.Knowledge of MS Office software, specifically Excel. Experience in developing and managing budgets. Experience in managing cross-functional, self-directed teams. Strong influencing, negotiation and analytical skills. Team advocate.