The Director of Medicare Operations is responsible for leadership, plan management, and operations of the CalOptima OneCare and OneCare Connect lines of business. The incumbent will provide direction to CalOptima’s departments to ensure compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC). The Director includes but not limited to coordination with clinical operations, regulatory relations, and subcontracted providers and health networks. This position involves interacting with all levels of CalOptima staff, members, providers, regulatory agencies, CalOptima Board, advisory committees, and representatives of other agencies as needed.
POSITION RESPONSIBILITIES:
- Coordination of all business operations associated the Medicare lines of businesses operations, health plan operations, including P&L responsibilities and coordination with and oversight of delegated health networks and contracted providers.
- Reviews and monitors OneCare and OneCare Connect financial performance; provides recommendations and develops action plans.
- Monitors and develops strategies for new member enrollment and continued retention.
- Oversees the development of strategic plans, work plans, and other initiatives for the OneCare and OneCare Connect health plan operations.
- Utilizing matrix management, directs and/or coordinates staff throughout the organization in the implementation of strategic work plans, development and implementation of new benefits, or other initiatives for health plan operations including but not limited to: CMS Five Star Program operational initiatives and Hierarchical Condition Category (HCC) maintenance and improvement activities.
- Coordinates data mining and data analysis activities for contracting and HCC improvement activities.
- Collaborates with staff from across the organization to research specific issues as necessary to develop and analyze solutions and make policy or programmatic recommendations to address operational issues.
- Communicates the plan’s operational issues; ensures adherence to work plans, identifies problem areas, develops solutions to issues or problems.
- Ensures implementation of Medicare program changes to comply with CMS regulatory requirements and is responsible for communication to stakeholders implement such changes.
- Ensures timely filing and compliance with CMS reports and data submissions.
- Reviews and recommends approval of OneCare and OneCare Connect program policies and procedures by the Executive Director.
- Other projects and duties as assigned.
Required Skills
- Motivate and lead various participants at all levels in the organization.
- Problem solve and think critically and creatively to solve complex problems.
- Direct and/or coordinate with staff from all CalOptima departments and disciplines in support of the CalOptima Medicare lines of businesses and its members.
- Ensure staff compliance with program rules and requirements, as well as work plans and identified tasks.
- Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, members, providers and the general public.
- Communicate effectively, both verbally and in writing.
- Review the reports for submission to CMS, the CalOptima Board of Directors, executive management or others, as required.
- Make operational, programmatic or other presentations to executive management, the CalOptima Board of Directors, or others as necessary.
- Identify pertinent policy issues and develop strategies, solutions and procedures.
- Direct, organize and track numerous and diverse projects, activities, timelines and issues.
Required Experience
EXPERIENCE & EDUCATION:
- Bachelor’s degree in Business Administration or related field required; Master’s degree preferred.
- Medicare Advantage health plan operations; Medicare Advantage HMO SNP experience preferred.
- Minimum 7 years experience in a management position of a health insurance plan, IPA, managed care organization, or public agency serving related populations.
- Project management experience strongly preferred.
KNOWLEDGE OF:
- Health insurance plan operations including but not limited to health care financing, managed care payment methodologies, and risk adjustment.
- Principles and practices of health care, health care systems, and managed care.
- Medicare, DHCS, DMHC and Knox Keene rules and regulations.
- CalOptima program, organizational structure and operations.
- Community-based organizations, agencies and community services.
- Principles and techniques of effective administration and supervision, including training and evaluation.
- Techniques of project planning and management, program and policy development, administration and coordination.
Grade: Q
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