Director of Medicare
Job Ref: 64119
Department: MEDICARE REGULATORY OPERATIONS
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $135,000.00
Salary Range: $135,000.00 - $140,000.00
About NYC Health + Hospitals
MetroPlus Health 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, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
Reporting to the Head of Product, the Director of Medicare ensures operational excellence and regulatory compliance of all Medicare products, owning the full spectrum of product strategy and operations. The Director will support key analytical activities to support the Plan’s strategic position, and will be proactive in identifying opportunities for performance improvement.
• Provide oversight of Plan and vendor operations as they relate to the Medicare line of business aligning outcomes to strategic goals & regulatory requirements.
• Develop & manage operational reports to track operational effectiveness.
• Partner with operational departments including Claims, Customer Service, Finance, Enrollment, Vendor Management, & Medical Management to design processes ensuring effective & efficient operations.
• Support key stakeholders in driving initiatives to meet quality & customer satisfaction goals.
• Maintain customer focus throughout Plan operations to ensure a seamless & excellent customer experience.
• Provide deep knowledge of & insight into the regulatory & market environment of Medicare in New York to support the development of product strategy.
• Identify & integrate operational best practices, partnering with key departments to optimize processes across the organization such as benefits administration, risk adjustment, marketing & communications, customer experience.
• Monitor & analyze regulatory activity ensuring compliant operations & implementation.
• Perform competitive & market analysis.
• Partner with internal & external stakeholders on key strategic, regulatory, & operational projects.
• Collaborate with Regulatory & Compliance teams to ensure timely implementation of Medicare regulatory & sub-regulatory guidance, coordinating tasks & workplans across impacted operational departments.
• Support the Regulatory & Compliance teams to ensure key requirements such as the development of audit universes, record & file pulls, data requests, & supporting documentation as they relate to external & Internal audits. Support plan staff in preparing for any audit activities or readiness reviews.
• Ensure success annual AEP in partnership with Marketing, Communications, & Customer Experience.
• Recruit, train, develop and motivate staff.
• Bachelor’s degree from an accredited college or university in an appropriate discipline required.
• Master’s degree in business, healthcare or public administration strongly preferred.
• Minimum 5 years experience at a Health Plan with Medicare Managed Care in a product management or
• Thorough knowledge of Medicare regulatory requirements, including risk adjustment.
• Experience working with enrollment & encounter processes.
• Thorough understanding of interconnected managed care operations
• Demonstrated ability to develop workflows, policies, procedures.
• Demonstrated ability to identify opportunities for improvement & implement solutions.
• Excellent written & verbal communication skills.
• Excellent analytical skills demonstrated by an ability to use actionable data to support decision-making, and to proactively identify opportunities
• Highly collaborative, and demonstrating good judgment in seeking consensus & input from multiple stakeholders to drive decision-making.
• Ability to take initiative & think independently
• Demonstrate understanding & acceptance of the MetroPlus Mission, Vision, & Values
• Business acumen
• Systems orientation
• Process improvement
• Data-driven decision-making
• Customer focus
• Written/oral communication
• Ability to work effectively in a fast-paced & constantly evolving environment