Medicare Operations Director
Hispanic Alliance for Career Enhancement, Chicago, IL, United States
Responsibilities
Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development.
Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls.
Lead business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders.
Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement.
Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking.
Manage vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS.
Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives.
Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff.
Qualifications
Minimum 5-7 years of Medicare Advantage operational experience.
Experience with health plan administration systems and platforms. Experience with Federal Employee Program or federal health benefits programs, preferred.
Background in both operational and technical aspects of MA plan administration preferred.
Experience working with FACETS claims processing system to manage healthcare claims adjudication, benefits configuration, and member eligibility, ensuring accurate and timely claims processing and resolution.
Experience leveraging AI technologies (machine learning, natural language processing, automation tools) to streamline operational processes and enhance customer experience, resulting in measurable improvements in efficiency, cost reduction, and customer satisfaction.
Familiarity with Agile/Waterfall project methodologies.
Proficiency in Microsoft Office Suite, particularly Excel and Visio.
Experience with requirements management tools preferred.
Demonstrated experience managing vendor relationships, preferably with system integrators.
Proven track record writing business requirements and supporting system implementations.
Experience working in health plan operations or similar healthcare environment.
Comprehensive understanding of Medicare Advantage regulations, CMS requirements, and compliance standards (including Star Ratings, RADV, risk adjustment).
Strong vendor management and contract oversight capabilities.
Excellent business analysis and requirements documentation skills.
Strategic thinking with ability to transition from tactical execution to long-term planning.
Proficiency in process improvement methodologies (Lean, Six Sigma).
Strong project coordination and organizational skills with ability to manage ambiguity.
Exceptional written and verbal communication abilities.
Proven ability to influence without authority and build consensus.
Change management and organizational development capabilities.
Ability to manage multiple priorities in a fast-paced, dynamic environment.
Previous experience in a matrixed organizational structure preferred.
PMP, PGMP, CBAP, or similar professional certification preferred.
Knowledge of healthcare data standards (HIPAA, X12, HL7) preferred.
Salary and Benefits The posting range for this position is $141,000 to $180,000. This job is also eligible for annual bonus incentive pay.
#LI-Hybrid
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account, and many other benefits to eligible employees.
#J-18808-Ljbffr
Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development.
Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls.
Lead business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders.
Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement.
Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking.
Manage vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS.
Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives.
Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff.
Qualifications
Minimum 5-7 years of Medicare Advantage operational experience.
Experience with health plan administration systems and platforms. Experience with Federal Employee Program or federal health benefits programs, preferred.
Background in both operational and technical aspects of MA plan administration preferred.
Experience working with FACETS claims processing system to manage healthcare claims adjudication, benefits configuration, and member eligibility, ensuring accurate and timely claims processing and resolution.
Experience leveraging AI technologies (machine learning, natural language processing, automation tools) to streamline operational processes and enhance customer experience, resulting in measurable improvements in efficiency, cost reduction, and customer satisfaction.
Familiarity with Agile/Waterfall project methodologies.
Proficiency in Microsoft Office Suite, particularly Excel and Visio.
Experience with requirements management tools preferred.
Demonstrated experience managing vendor relationships, preferably with system integrators.
Proven track record writing business requirements and supporting system implementations.
Experience working in health plan operations or similar healthcare environment.
Comprehensive understanding of Medicare Advantage regulations, CMS requirements, and compliance standards (including Star Ratings, RADV, risk adjustment).
Strong vendor management and contract oversight capabilities.
Excellent business analysis and requirements documentation skills.
Strategic thinking with ability to transition from tactical execution to long-term planning.
Proficiency in process improvement methodologies (Lean, Six Sigma).
Strong project coordination and organizational skills with ability to manage ambiguity.
Exceptional written and verbal communication abilities.
Proven ability to influence without authority and build consensus.
Change management and organizational development capabilities.
Ability to manage multiple priorities in a fast-paced, dynamic environment.
Previous experience in a matrixed organizational structure preferred.
PMP, PGMP, CBAP, or similar professional certification preferred.
Knowledge of healthcare data standards (HIPAA, X12, HL7) preferred.
Salary and Benefits The posting range for this position is $141,000 to $180,000. This job is also eligible for annual bonus incentive pay.
#LI-Hybrid
We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account, and many other benefits to eligible employees.
#J-18808-Ljbffr