Executive Job Description | Morgan Consulting Resources is an executive search firm focusing on the Healthcare Industry for 15 years. We have extensive experience in bringing together leadership talent with organizations that cover all aspects of Healthcare Services - Providers, Payers and Supporting Service organizations.
We have been retained by a healthcare management group to perform a national search for an Director of Medicare Operations based in Southern California.
About the organization:
Our client is a public entity and community-accountable health plan serving residents of Los Angeles County through a variety of programs including Medi-Cal, Healthy Families, our client’s Healthy Kids and our client’s Medicare Advantage Special Needs Plan.
Our client is a leader in developing new programs through innovative partnerships designed to provide health coverage to vulnerable populations and to support the safety net. With nearly 800,000 enrolled members, our client is the nation’s largest public health plan and has been awarded an Excellent Accreditation by the National Committee for Quality Assurance.
About the position:
Reporting to the Sr. Director of Member and Medicare Services, the Director of Medicare Operations will manage a team of seven (2000 Medicare Advantage Special Needs Plan members—dual eligibles). He or she works closely with our client’s leadership team and operational areas to ensure the organization is meeting Medicare’s specific needs. The position has many matrix responsibilities requiring a wide breadth of understanding of the insurance industry, managed care operations and in particular, the Medicare program. The Director of Medicare Operations specific responsibilities include:
• liaison between operational areas and compliance as it relates to the specific needs of the product;
• growth and financial projections;
• HCC optimization* and management; and,
• Policy and governmental impact assessment, including impacts of changes in policies or financing, financial performance and contracting, product strategy and coordination of that strategy between other operational areas including annual CMS bid.
The Director of Medicare Operations will also require significant level of skill in managing external and internal relationships, the ability to see the larger needs of the organization and community at large, and the leadership skills and tact to get this accomplished in a complicated environment. The Director is responsible for formulating new and existing Medicare strategies and plans in concert with leadership from other areas such as Marketing, Sales, Finance, and other Operational departments. This position is responsible for defining and meeting specific product metrics as well as monitoring company performance against the product’s specific goals. Other responsibilities include oversight of new enrollment application processing and development of annual new member materials.
We are looking for an enthusiastic self-starter. The successful candidate will come from a fast-paced environment. He or she will have strong communication skills, an even-keeled personality and creative approaches to problem resolution. Having the ability to work well with other departments within a health plan is critical.
Please see attached position description for further qualifications and requirements.
The company offers a competitive compensation package. If you are aware of someone with some of these skill sets, please let us know. As always, we value your input and look forward to catching up with you soon, (702) 968-8050.
*Direct knowledge of Hierarchical Classification Codes (HCCs) not needed, but overall management of a specialist in this area will be required.
Rosie Saenz, Principal
Morgan Consulting Resources, Inc.
(702) 968-8050; (702) 561-8226 cell
rosie@morganconsulting.com
www.morganconsulting.com
your resource for health care executives
Promotional Job Description
Provide a concise, 4 - 5 sentence description of the key job duties and requirements for consideration to be used for advertising, job posting and applicant screening purposes. Be specific, spell out acronyms, and focus on technical skills and requirements.
The Director of Medicare Operations works closely with our client’s leadership team and operational areas to ensure the organization is meeting Medicare’s specific needs. The position has many matrix responsibilities requiring a wide breadth of understanding of the insurance industry, managed care operations, and in particular the Medicare program. The Director of Medicare Operations specific responsibilities include; liaison between operational areas and compliance as it relates to the specific needs of the product; growth and financial projections; HCC optimization and management; policy and governmental impact assessment, including impacts of changes in policies or financing, financial performance and contracting, product strategy and coordination of that strategy between other operational areas including annual CMS bid. The Director of Medicare Operations will also require significant level of skill in managing external and internal relationships, the ability to see the larger needs of the organization and community at large, and the leadership skills and tact to get this accomplished in a complicated environment. Reporting to the Sr. Director of Member and Medicare Services, the Director is responsible for formulating new and existing Medicare strategies and plans in concert with leadership from other areas such as Marketing, Sales, Finance, and other Operational departments. This position is responsible for defining and meeting specific product metrics as well as monitoring company performance against the product’s specific goals. Other responsibilities include oversight of new enrollment application processing and development of annual new member materials.
DIMENSIONS: Complete the following qualitative data, if applicable.
1. Total Staff (including direct and indirect reports) 7
2. Annual Operating Budget
3. Other Scope Measurements
Essential Functions of the Job End Results Expected % of Time
1 Ensure all functions necessary for the organization, support, operation and advancement of the Medicare line of business is performed efficiently and effectively. 40
2 Anticipate critical issues and opportunities created by changes in the wider business, operations or regulatory/compliance environments, and present possible strategies to Leadership that are well thought out and thoroughly examined. 20
3 Ensure Medicare sales and enrollment processing is compliant and meets regulatory deadlines. 10
4 Assist Regulatory Affairs and Compliance Department in the implementation of State and Federally mandated program changes. 10
5 Monitor CMS submissions and collection of Medicare Revenue. Work closely with Medical Management, Finance and Healthcare Outcomes & Analysis on HCC/Risk Adjustment 10
6 Lead annual bid preparation and submission, working closely with Finance, Sales & Outreach, PNO, Medical Management, Pharmacy, etc., including identifying, contracting and managing external actuary firm to assist in the process. 10
Subordinate Job Titles (if any):
Medicare Operations Manager
Supervisor, Medicare Enrollment
Medicare Operations Specialist
Medicare Enrollment Specialist
Medicare HCC Specialist
Education, Training and Experience for the Position:
Required Preferred
Education/Training Bachelor’s degree required. At least 10 years of healthcare management experience with 3+ years with the Medicare program. Knowledge of managed care environment. Excellent verbal and written communication skills. Graduate degree in public health, public policy or business administration preferred. Supervisory experience preferred.
Foreign Languages Spanish
Physical Requirements:
Sedentary Sedentary: limited activity, no lifting, limited walking
Working Relationships:
List the titles of individuals typically contacted, other than the direct supervisor or subordinates
Contacts Inside? Reason for Contact Frequency of Contact
CMS No Operations Director will be one of the primary contacts with CMS. Operations Director will be working on regulatory and compliance issues as well as submitting materials for CMS approval.
Weekly
Actuarial Firm No In preparation for CMS annual bid. Weekly
Sales and Outreach Yes To ensure that all sales staff have the information and training they need and that staff are operating within CMS sales and marketing regulations.
Daily
Finance Yes To help ensure that any payment discrepancies are resolved and that submissions to CMS that may impact Medicare revenue are accurate.
Weekly
Medical Management/Claims Yes To be a resource for any policy or benefit changes that may impact our client's Medicare members are communicated clearly and that UM has a resource for any policy or benefit interpretation needs that may come up.
Weekly
HCC Vendor No Manage relationship in support of HCC Chart
Audits and Risk Adjustment Management to ensure revenue maximization.
Weekly
PNO Yes To provide support for PNO as we continuously evaluate our network for adequacy, and as a resource for provider training program development.
As needed
Member Services To ensure that member services is supported in terms of information and requirements that will impact members. To work with management as they continuously evaluate how member services is provided.
Weekly
Responsibility and Decision-Making
Describe the types of decisions made and the types of decisions referred to others
Types of decisions made without prior approval:
Day-to-day operations decisions and interpretation decisions that do not constitute material changes to program delivery or could create political or regulatory attention on the organization. Those decisions should be vetted at the very least with the Sr. Director of Member and Medicare Services if not the client leadership group.
Types of decisions referred to higher authority:
Any changes that could affect Medicare Member benefits or could require regulatory approval
How is the work assigned and reviewed, and what is the frequency and type of guidance provided by the supervisor:
The Operations Director will meet with Sr. Director of Member and MedicareServices 1:1 at least biweekly, and as needed. During those meetings the Operations Director's work will be assigned and reviewed.
Major Challenges
Describe 2-3 of the most difficult problems faced in doing the job and the means by which they are resolved
Challenge Approach/Solution
Effective Communication across our client's functional areas. Regular contact with the different operational areas of the organization and communication that uses multiple methods of delivery. (in person, email, phone, repetition or messages etc.)
The ability to manage multiple issues concurrently. Use resources that are provided. Director support and support of peers will be key to the successful management of our client's Medicare program.
Persuasion Skills
Provide examples of the need to persuade or convince others to accept the actions or recommendations of the position
When a regulatory change that impacts the Medicare program occurs, it will be incumbent on the Operations Director to be able to clearly communicate that change and help the impacted areas develop solid executable decisions. It will be important for the Operations Director to use persuasion skills to help avoid bad decisions before they are executed and the ability to persuade others not to execute what may be a bad decision will be key.
Financial Impact
Provide any financial measures that the job impacts: payroll; budget; accounting records; capitation; etc.
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