Under the general direction of the VP of Government Programs Administrative Operations, this position is responsible for assuring that all Government Programs products are administered according to approved benefit design and regulatory requirements. The incumbent is accountable for service and operational requirements associated with the products including regulatory requirements set forth by the Centers for Medicare & Medicaid Services (CMS), NCQA guidelines, the New York State agencies including the Department of Finance Services and Department of Health and applicable Federal and State rules and regulations
Essential Responsibilities/ Accountabilities
• Conducts evaluation, review, and assessment of various operations for the purpose of identifying root causes of operations problems that contribute to noncompliance and customer dissatisfaction.
• Consults with team members and stakeholders to streamline system operations and processes to improve business effectiveness and efficiency.
• Plans, develops and implements special projects, initiatives and activities to support product, benefit administration and regulatory requirements.
• Develops strategic, operational and tactical business plans to achieve desired business goals for the Government Programs lines of business.
• Encourages innovation, process improvements and personal development within the Operations Team.
• Develops and maintains relationships across the enterprise to promote consistent strategic priorities.
• Collaborates with cross functional teams to ensure compliance, improve operational performance and drive process improvement.
• Ensures cross functional integration of strategies with key internal areas including Business Technology, Finance, Provider Contracting, Clinical Operations and Compliance. Represents Administrative Operations on related key cross-functional committees to ensure Government Programs perspective is being integrated into strategies of other areas.
• Provides direction and supervision to the staff including departmental functions, individual development plans, performance reviews, and disciplinary actions. Responsible for coordinating communications and daily activities of the staff, and assuring adequate staffing to accomplish corporate goals.
• Reads, interprets and identifies necessary next steps related to complex government regulations.
• Engages in issue identification as well as problem solving to identify and resolve potential improvement opportunities.
• Acts quickly to continuous changes and challenges in the regulatory environment.
• Works closely with other Departments for input and integration. Ensures all perspectives are taken into account and develops processes and timelines to incorporate planning and execution of strategies across departments.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
• Bachelor’s degree in health administration, marketing, business administration or related field with a minimum of six years progressive health plan operations experience.
• Strong leadership and/or management experience.
• Strong expertise and background dealing with regulatory and accreditation agencies such as NCQA, CMS, Federal & State agencies including DOH, Dept. of Finance Services.
• Remain current on all relevant regulatory requirements.
• Strong process and program management skills, analytical, creativity and initiative in problem solving and solution identification.
• Must be a critical thinker and possess effective negotiation skills in dealing with middle and senior management levels.
• Must possess strong computer skills, including MS Word, Excel and PowerPoint.
• Must possess strong, demonstrated analytical ability, strategic thinking and creativity as well as a positive attitude, strong work ethic and highly effective communication skills.
• Must be capable of establishing effective relationships with all levels of representation throughout the divisions including senior management in order to execute cross-divisional initiatives.
Excellus BlueCross BlueShield - 15 months ago