Job Summary
This position is responsible for assisting with ensuring ongoing compliance and operational performance of new and extant Medicaid, Medicare and Commercial programs and projects. Works both independently and collaboratively with all health plan functional areas with the purpose to support the development, implementation, maintenance, monitoring, and continuous improvement of the Medicaid, Medicare and Commercial lines of business. Must possess advanced organizational and matrixed management skills to manage the highly complex ongoing and periodic processes including but not limited to the dissemination and verification of the implementation of regulatory and sub-regulatory guidance and rule changes issued by the products regulatory authorities, filing various documents, forms and responses to each regulatory authority and management of many periodic processes including but not limited to Medicaid, Medicare and Commercial program bid submission, periodic Service Area Expansions, MA and HIX Call letter implementation, annual readiness review attestation, and Commercial product and rate development. This position may be responsible for supervising and directing Medicaid, Medicare and Commercial Programs that provides the clerical and technical support for the Health Plans.
Essential Functions
Ensures all Medicaid, Medicare, MA and Commercial (both on and off the exchange) regulatory, sub-regulatory and policy guidance are disseminated in a timely manner and that such guidance is strictly adhered to, implemented and monitored and that evidence of implementation is verified and documented.
Manages the annual Medicaid, Medicare, and MA Bid process and periodic Commercial product and rate development. Manages the Service Area and Market Expansion process as necessary.
Manages or oversees the submission of all required materials and forms (i.e. Formulary Submission, annual website updates, marketing materials, Low Income Subsidy (LIS) match rates, monthly encounter data and Part C and D reporting, Policies, Evidence of Coverage) and data to the regulatory body overseeing a particular line of business.
Manages the development of the New Member Notifications. Assists Marketing with the production of all member materials for the Medicaid, Medicare and Commercial lines of business. Assists all functional areas with ensuring they are using the most current model member communications.
Attends all relevant AHCCCS, CMS, ADOI and CCIIO user group calls and meetings.
Assists with researching and tracking the Medicaid, Medicare and Commercial legislative environment and initiatives in collaboration with Legislative Affairs. Ensures the regulatory reporting requirements for the Medicaid, Medicare and Commercial lines of business are timely, accurate and compliant.
Manages the production of the Monthly Operational Dashboard. Ensures functional areas are compiling and reporting the data that comprise the Monthly Medicare Compliance Dashboard.
Collaborates with Network Development to ensure Medicaid, Medicare and Commercial Provider contracts meet regulatory requirements.
Minimum Qualifications
Must possess a knowledge as normally obtained through the completion of a Bachelors degree in health care administration, finance administration or project management or equivalent combination of work experience.
This position requires the skills, knowledge and abilities typically acquired over one year of related experience and education. The work requires a high degree of organization, the ability to manage time and resources effectively, and the self-starter ability to work independently to achieve goals. Effective customer service and interpersonal relations skills are necessary. The ability to communicate effectively verbally, in writing and through common computer software is required.
Preferred Qualifications
Health Plan and Case Management experience and prior experience working in Medicaid and/or Medicare health plans preferred
Additional related education and/or experience preferred.
