In support of the Chief Medicare Officer, the Director Medicare (MDCR) Operations is responsible for ensuring that the local Medicare business is compliantly and effectively operating in the market. As such, the Director of Medicare Operations supports MAPD and SNP initiatives and implements and oversees activities and programs across the market to achieve earnings and growth objectives.
Additional Responsibilities as a Director Medicare (MDCR) Operations Include:
Direct operational functions of Medicare products across a market as directed by the Chief Medicare Officer (acting as Chief Operating Officer)
Responsible for AEP operational readiness including the education and training of Sales team, telesales and customer service teams
Develops recommendations for Service Area Expansion/SAR's/Product terms
Ensures that market Medicare network is adequate and optimized for customer marketability and works closely with the network team to support and ensure provider data accuracy
Responsible for all operational aspects of Joint Venture partnerships
Provides operational support for market management of plan sponsors, members and network providers
Participates in various committees to represent the Medicare department including NCQA, Internal Research, UM, QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, migration, etc.
Has shared responsibility for all CMS, Bid and application activities
Serves in a strategic capacity in the bid process as it relates to product and benefit design, competitive analysis, membership modeling, and Contract/PBP strategy
Maintains awareness of trends and developments in Medicare and managed health care organizations
Uses competitive intelligence to guide, consult and drive product implementation and strategic focus for Medicare Part D and Medicare Advantage
In partnership with the Product organization, responsible for the oversight and execution, at the local market level, of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, group set up
Develops Sales and Membership model in conjunction with CMO and Enterprise; accountable to ensure that all customer and broker facing material is accurate and compliant
Responsible for Member Retention and member experience initiatives.
Manages Member Retention Specialist(s)
Leads member retention activities, including development of outreach material, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues
Develops and implements business strategies to provide accurate and proactive customer service to members, plan sponsors and brokers
Maintains current knowledge of State and Federal regulations.
Monitors sales and marketing activities to assure adherence to Federal and State regulations
Coordinates strategies and recommends policy positions with senior management regarding legislative issues and regulatory with a key support function in program and project management in support of Medicare Advantage and Medicare Part D, including Stars, Revenue Management, Quality and Network concerns
Represents Chief Medicare Officer in strategic and leadership meetings as needed.
In partnership with Operations Integrity and at the direction of the Chief Medicare Officer, may facilitate internal and external Medicare audit activity including CMS and operations integrity audits. Coordinates file pulls, data requests, universe development and supporting documentation
May, depending on local market needs, develop market-based risk adjustment strategies and drive execution of critical revenue related activities such as medical record capture and in-home assessments
Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions, including employment, termination, performance reviews, salary reviews and disciplinary actions
Medicare operational experience highly desired
Ability and experience working effectively cross-functionally - Leadership and Supervisory experience
Excellent written and verbal communication skills
At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.
We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.