Director of Medicare Product

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

MetroPlusHealthis committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

The Director of Medicare Product serves as the subject matter expert and resource for all departments and intergovernmental, federal regulatory agencies related to various Medicare products and operations to ensure compliance.

• Provide a resource to all operational departments regarding the Medicare management. Communicate any changes to Medicare management, either regulatory or otherwise to all departments. Must be and remain current with all applicable Medicare regulatory requirements for marketing, enrollment, operations, billing, claims, etc.
• Coordinate implementation of interdepartmental processes (policies and procedures) related to Medicare business. Assist the Regulatory Affairs Department with implementing state and federally mandated program changes.
• Assist with new program development and communications.Assist in the development, review and approval of marketing, member and provider-related or other materials.Responsible for ensuring appropriate and compliant materials are produced and distributed. Work with the Regulatory Affairs Department to receive approval of all such materials.
• Responsible for annual Medicare Bid submission ensuring Plan Benefit accuracy while working with internal departments.
• Research and create market analysis ensuring competitive and marketable benefit packages are offered.
• Develop and monitor operational dashboards and KPI's to ensure operational effectiveness & compliance.
• Perform root cause analysis of identified issues, in partnership with other departments as necessary, to identify opportunities for improvement, and develop innovative solutions.
• Provide oversight of plan & vendor operations as they relate to the Medicare line of business, aligning outcomes to strategic goals & requirements while ensuring Service Level Agreements are adhered.
• Participate in medical cost discussions and evaluate programs to maximize revenue and decrease costs. Oversee and develop programs to improve and manage benefit delivery.
• Actively participate in the Centers for Medicare and Medicaid Services (CMS) site visit preparation and in any corrective actions, including review survey documents, training departments. Attend provider sessions dealing with Medicare issues, as requested.
• Coordinate efforts of any consultants or internal work groups to insure consistent focus on the MetroPlus Medicare program requirements.

• A Bachelor's degree required. Master's degree preferred from an accredited college or university; and,
• Minimum 8 years of experience, including 5-7 years in a SME or leadership role, within the fields of Administration, Business Administration, Public Administration or an equivalent field, including substantial exposure in meeting community needs; or,
• An equivalent combination of training, education and experience in related fields and educational disciplines; and, Thorough knowledge of the fundamentals of the organization, administration and standards, regulations and laws applicable to operations, knowledge of business and management functions, management processes and functions of departments, and the ability to direct and supervise personnel.
• 5-7 years of Medicare management, operations and/or federal and state regulatory compliance experience.
• Experienced health care professional who is able to provide direction in a competitive environment and an evolutionary business.
• Detailed knowledge of healthcare, specifically managed care and insurance regulations.
• Significant and demonstrable experience with Medicare, Medicaid, Dual Eligible populations and regulations including operational and regulatory requirements around Medicare Special Needs programs e.g., HIV.
• Must possess a strong understanding of the healthcare industry marketplace via tenure at a managed care or ancillary healthcare services organization.
• Requires strong analytic and strategic planning skills. Must be able to successfully facilitate sound business objectives within highly regulated industry.
• Demonstrated ability to handle multiple tasks simultaneously.
• Exceptional written and oral communication.
• Demonstrated ability to analyze a marketing challenge and determine appropriate initiatives in response to research results.
• Experience in Medicare managed healthcare or ancillary healthcare services industry (e.g., pharmaceuticals, diagnostics).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication

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