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Director, Medicare Operations

Blue Bell, Pennsylvania
Job Type
1 Oct 2021
Job Description

In support of the Chief Medicare Officer, the incumbent has responsibility for ensuring that the local Medicare business is compliant and effectively operating in the market. As such, the Director of Medicare Operations supports MAPD and SNP initiatives and implements and oversees activities and programs across the market to achieve earnings and growth objectives. This role will have a significant impact on helping to achieve continued growth in the Keystone Region, Aetna's flagship market.

Additional Responsibilities as a Director Medicare (MDCR) Operations Include:

* Direct operational functions of Medicare products across a market as directed by the Chief Medicare Officer (acting as Chief Operating Officer)
* Responsible for AEP operational readiness including the education and training of Sales team, telesales and customer service teams
* Develops recommendations for Service Area Expansion/SAR's/Product terms
* Ensures that market Medicare network is adequate and optimized for customer marketability and works closely with the network team to support and ensure provider data accuracy
* Responsible for all operational aspects of Joint Venture partnerships
* Provides operational support for market management of plan sponsors, members and network providers

Participates in various committees to represent the Medicare department including NCQA, Internal Research, UM, QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, migration, etc.

* Has shared responsibility for all CMS, Bid and application activities
* Serves in a strategic capacity in the bid process as it relates to product and benefit design, competitive analysis, membership modeling, and Contract/PBP strategy
* Maintains awareness of trends and developments in Medicare and managed health care organizations
* Uses competitive intelligence to guide, consult and drive product implementation and strategic focus for Medicare Part D and Medicare Advantage
* In partnership with the Product organization, responsible for the oversight and execution, at the local market level, of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, group set up
* Develops Sales and Membership model in conjunction with CMO and Enterprise; accountable to ensure that all customer and broker facing material is accurate and compliant

Responsible for Member Retention and member experience initiatives.

* Manages Member Retention Specialist(s)
* Leads member retention activities, including development of outreach material, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues
* Develops and implements business strategies to provide accurate and proactive customer service to members, plan sponsors and brokers

Maintains current knowledge of State and Federal regulations.

* Monitors sales and marketing activities to assure adherence to Federal and State regulations
* Coordinates strategies and recommends policy positions with senior management regarding legislative issues and regulatory with a key support function in program and project management in support of Medicare Advantage and Medicare Part D, including Stars, Revenue Management, Quality and Network concerns

Represents Chief Medicare Officer in strategic and leadership meetings as needed.

* In partnership with Operations Integrity and at the direction of the Chief Medicare Officer, may facilitate internal and external Medicare audit activity including CMS and operations integrity audits. Coordinates file pulls, data requests, universe development and supporting documentation
* May, depending on local market needs, develop market-based risk adjustment strategies and drive execution of critical revenue related activities such as medical record capture and in-home assessments
* Recruits, develops, and motivates staff. Initiates and communicates a variety of personnel actions, including employment, termination, performance reviews, salary reviews and disciplinary actions

Required Qualifications

* Significant (9+) years' experience in Medicare or equivalent managed care operational and technical skills.
* Bachelors degree
* Subject matter expert in regulations and statutes impacting the Medicare business.
* Ability to perform analysis and legal research to identify and clarify issues.
* Business acumen and experience with managing complex processes.
* Excellent written and verbal communication skills; ability to conduct external presentations and represent Aetna in business and provider meetings

COVID Requirements

COVID-19 Vaccination Requirement

CVS Health requires its Colleagues in certain positions to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, pregnancy, or religious belief that prevents them from being vaccinated.

* If you are vaccinated, you are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status within the first 30 days of your employment. For the two COVID-19 shot regimen, you will be required to provide proof of your second COVID-19 shot within the first 60 days of your employment. Failure to provide timely proof of your COVID-19 vaccination status will result in the termination of your employment with CVS Health.
* If you are unable to be fully vaccinated due to disability, medical condition, pregnancy, or religious belief, you will be required to apply for a reasonable accommodation within the first 30 days of your employment in order to remain employed with CVS Health. As a part of this process, you will be required to provide information or documentation about the reason you cannot be vaccinated. If your request for an accommodation is not approved, then your employment may be terminated.

Preferred Qualifications

* Experience in managing a multi-disciplinary, virtual team
* Familiarity with Aetna and CVS culture, processes and systems


* Bachelors degree. Masters preferred.

Business Overview

At Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.
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  • Job Reference: 386582996-2
  • Date Posted: 1 October 2021
  • Recruiter: CVS Health
  • Location: Blue Bell, Pennsylvania
  • Salary: On Application
  • Sector: Executive Positions
  • Job Type: Permanent