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 Health's 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 Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
