Director, Medicare Operations

AIM HealthCare Services, Inc. is a nationally recognized consulting firm, based in Nashville, Tennessee, that was established in 1995 and has grown from 2 employees to over 1800 in 2007. We provide consulting services to Insurance companies and Hospitals throughout the nation.

We are currently seeking an enthusiastic, success-driven professional to join our team as a Director of Medicare Operations. AIM is looking for experienced self-starters who are looking for an opportunity to grow with their company.

The Director of Medicare Operations is responsible for the development, implementation and ongoing oversight of the operations and revenue reconciliation activities needed to support Medicare Advantage Part C and Part D. This individual will ensure that relevant policies and procedures, state and federal Medicare program requirements are implemented to achieve effective, efficient, auditable and compliant operations.

PRIMARY RESPONSIBILITIES:

1. Develops, implements and oversees operational processes to ensure maximization of Medicare Advantage and Part D premium revenue methodology, including effective member/premium reconciliation, accurate and timely transaction processing.
2. Develops Standard Operating Procedures and defines process flows to establish monthly revenue reconciliation processes.
3. Develops, implements and oversees corresponding policies and processes for state payments of Medicare cost-sharing and state-funded benefits.
4. Develops control plans and charts to monitor enrollment reconciliation efforts.
5. Monitors plans and distributes periodic reports to division management and functional partners.
6. Ensure accurate and timely administration, coordination, reporting and reconciliation of Medicare enrollment, special statuses and other elements affecting member premiums.
7. Work with the pharmacy benefits management vendor to ensure accurate and timely administration, coordination, reporting and reconciliation of Part D enrollment, pharmacy encounter data, reinsurance and low income subsidy payments; and other health insurance information.
8. Develops and monitors management reports that measure expected service levels, data and processing quality, and production volumes of all operational and revenue components.
9. Increases the organization’s knowledge and understanding of Medicare program requirements through presentations and training materials related to enrollment and premium reconciliation.
10. Contributes to the growth of the Medicare line of business by developing, modifying and improving business processes, policies, and target environment as needed.
11. Implements new Medicare Advantage requirements consistent with CMS requirements.
12. Implements effective and appropriate program communications plans.
13. Monitors relevant state and CMS systems, guidance and notices.
14. Leads initiatives to communicate changes and modify processes and documentation as needed .
15. Ensures successful internal and external audits by working with operational teams to maintain compliance with regulatory requirements and requirements for financial and operational controls.
16. Ensures adherence to appropriate processes, methodologies, policies and procedures.
17. Identifies and resolves any issues that may hinder program success.
18. Serves as the Medicare Advantage liaison to the Sales and Marketing team, Network Management and external vendors.
19. Analyzes identified discrepancies, understands discrepancy root cause, and recommends system enhancements to prevent discrepancy in the future.
20. Other Duties as Assigned.


Education/Experience

College Degree or equivalent experience required

5+ years experience with Medicare Advantage Healthplan

Detailed understanding of Medicare Advantage Part C and Part D regulatory requirements.

Experience managing the Medicare Advantage Revenue Cycle.

Knowledge of Medicare Advantage Part C and Part D or other demonstrated comparable experience in developing government program compliance auditing and monitoring programs that access regulatory risk.

Experience implementing or coordinating the implementation of new regulatory requirements, corrective action plans and process improvement initiatives for Medicare Advantage Part C and Part D products.

Understands RAPS submission and Hierarchical Condition Category (HCC) with Disease Interaction processes.

Knowledge of Actuarial and Plan Bid processes a plus.


In addition to competitive salary, we provide a full range of benefits including medical, dental, life, short and long term disability, vacation, personal days, and a matching 401k. AIM will reimburse expenses required for maintaining credentials. For immediate consideration apply online by using the following link:  https://www.aimhealth.com/ats/JobDetails.aspx?id=2296 Applications & resumes without a specific salary requirement will not receive first consideration. No phone calls please.


Please visit our website for more information regarding AIM HealthCare Services at: www.aimhealth.com

AIM Healthcare Services, Inc. is an equal opportunity employer