Responsible for the operational development, project management and, end to end business processes of new and existing health plan products. This position may focus on the Medicare & Medicare Part D or State Government Programs and Individual Markets within the Government Programs, Customer Care or FLRx Divisions, respectively. Keeps senior management apprised of operational development and implementation activities through written and oral reports.
May include the following depending on Divisional responsibilities:
• Leads operational development of new and existing health plan products.
• Leads projects and initiatives for the operational business areas of responsibility for the respective division. May include but are not limited to: operational procedures impacting Enrollment, or Call Center units, benefit administration, financial arrangement, systems development, member contracts and legislative/regulatory changes.
• Defines detailed business components and requirements necessary to articulate business specifications and guide the development of end user requirements and workflow specifications.
• Leads projects effectively, prioritizes workload and manages change.
• Participates in product driven workgroups to provide input to product designs, regulatory changes and, implementation plans.
• Works closely with cross functional teams such as Enrollment, Call Center, Compliance, Sales, Finance, Clinical/Network Management, and senior management in planning and implementing new products, product enhancements, projects, business implementations and, end to end process improvements. Keeps all areas of the corporation informed through written and oral reports. Ensures communication to all areas impacted.
• Represents Division both internally and externally in areas of expertise. Serves as a product and benefit consultant for major account implementations of customized products and services.
• Develops process improvements utilizing methodologies and principles that align with corporate goals to conduct process modernization projects, identifying best end to end practices.
• Creates process documentation, workflows and training materials.
• Continuously works to identify, analyze and remove barriers to increased productivity, quality, cost effectiveness, timeliness of operations, and customer satisfaction.
• Serves as the subject matter expert on regulatory requirements and product requirements to other business units.
• Writes and speaks fluently on all aspects of work. Communicates effectively with users/customers, colleagues and across a range of disciplines, and all levels of management.
• Invokes appropriate escalation, as needed.
• Plans, schedules, monitors, and reports on activities related to a project or assignment.
• 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.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.
Medicare Part D Focus, only:
• Performs claim reviews and reconciliation to established standards and develops processes to remediate errors detected.
• Serves as the operational liaison to the Medicare Part D claims processor for the health plan
• Responsible for maintenance of Medicare Part D EOBs.
• Supports CMS audits of Part D functions. Fulfills audit universe and sample requests received from auditors. Participates in audits as needed.
Level II - performs these additional responsibilities:
• Manages projects of large complex scope with multiple cross functional teams.
• Communicates and comprehends business strategy and drives strategic recommendations and facilitates related implementations.
• Applies advanced methodologies of process improvements and research techniques in the investigation, solution of complex end to end processes.
• Provides leadership and mentoring to less experienced personnel.
• Serves as a subject matter expert in multiple areas or products within the division.
• Bachelor’s degree in marketing, communications, business administration, pharmacy management (Medicare Part D specific) or similar discipline with a minimum of three years in marketing or operational disciplines. Master’s Degree preferred. In lieu of a degree, a minimum of six years of experience within a customer service or government program role.
• Health care industry experience preferred.
• Excellent communication skills and strong analytical ability required.
• Ability to work cross-functionally across departments and divisions.
• Ability to adapt to constant change and competiting priorities and ability to manage multiple projects simultaneously.
• Must show initiative and creativity in assessing the trends in the marketplace and recommending their impact on the product portfolio.
• Must be able to think strategically while managing tactical execution.
• Remains current on all relevant regulatory requirements
Level II – requires similar qualifications as level I, as well as:
• Bachelor’s degree in marketing, communications, business administration, or similar discipline with a minimum of five years of marketing or operational disciplines. Master’s Degree preferred. In lieu of a degree, a minimum of eight years of experience within a customer service or government program role.
• Certification in Project Management, Lean Practitioner or Lean Six Sigma or equivalent discipline certification preferred.
• Demonstrated leadership, decision making and team building skills.
Travel to other regions within the corporation.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Excellus BlueCross BlueShield - 30+ days ago