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Director Health Plan Administrative Operations
4 months ago
General Summary of Position
Reporting directly to the Vice President/COO of MedStar Family Choice Health Plan Operations, the Director will develop and implement a strategy to expand and increase E2E health plan administrative operations performance and oversight in collaboration with MedStar Family Choice and Strategic Partner leadership. This role will support enrollment and market expansion aspirations through the delivery of efficient and effective service delivery, enabling technology, collaborative relationships and demonstrated results to meet the healthcare needs of the MedStar Family Choice membership and communities it serves. Supervises and directs the activities of various levels of assigned personnel using both professional and supervisory discretion and independent judgment for claims, service, benefit configuration, new member enrollment, encounter data integrity, provider data integrity and vendor performance oversight (in partnership with Director of Vendor Contracting team). The objective of this role is to provide end-to-end health plan operations subject matter expertise to ensure optimal performance and efficiencies, reduce operating costs, foster accountability and excellence, create a culture of collaboration, and increase new member enrollment and retention.
Primary Duties and Responsibilities
Provides effective oversight and management of critical health plan administrative operations including vendor partner functions (claims, benefit maintenance, provider maintenance, EDI, encounter data, provider contract and pricing, service, audits, digital tools) and assists with overall vendor effectiveness. Facilitates recurring and ad hoc strategic and tactical engagements with the vendor and optimizes operational workflows and contractual agreement. Calibrates quality audits/reviews when root causes are identified and works diligently ensuring root cause resolution.
Develops and implements a strategy in collaboration with health plan partners to identify successes and root cause deficiencies to improve all elements of health plan operations with the goal of supporting sales and membership growth.
Directs and oversees risk management reporting related to health plan administrative operations functions. Develops, coordinates, and administers systems for risk identification, investigation, and reduction.
Oversee complex operational outcomes of the new member enrollment functions for MD and DC assigned lines of business. Serve as subject matter expert for the administrative operations functions of the operations organization and applicable vendor partners and is a problem solver.
Manages the administrative functions of the department including budgeting, staffing, and performance management, and ensures the department is adequately staffed to address the needs.
Ensures exceptional customer service by driving continuous improvements for all aspects of the claims/accounts, providing professional and timely feedback to vendor partner(s) and internal claims teams to meet quality, cycle time, SLA's and financial standards as outlined in all applicable MSAs, SOWs and MD/DC contracts.
Drives the resolution of claims by collaborating with internal and external business, vendor partners, and state governance entities to develop, own and execute a claim resolution strategy, that includes management of timely and accurate adjudication while collaborating with coverage experts.
Oversees in partnership with the DVOC team, all third-party COB, payment integrity, subrogation/salvage opportunities or potential fraud occurrences by evaluating the facts of the claim and making appropriate referrals to appropriate Claim, Recovery or SIU resources for further investigation.
Oversee negotiating complex claim settlements and the oversight and audit of high-dollar payments within scope of authority as defined by MSA and SOWs.
Verifies coverage, sets and manages timely and adequate reserves by reviewing and interpreting policy language and partnering with coverage counsel as needed, estimating potential claim valuation, and following MedStar Family Choice and vendor partner claim handling protocols.
Plays a key role in developing and executing the member and provider experience/engagement strategy, focusing on delivering exceptional customer experience and driving satisfaction, loyalty, and retention across multiple touchpoints.
Lead internal benefit configuration team and oversee vendor partner team with new benefit acquisition/implementation, upgrades, business rule changes, effective and modifiable testing processes and interactions with Information Technology when supporting core system upgrades.
Performs other job-related duties as assigned.
Minimum Qualifications
Education
Bachelor's degree Health Care Administration, Public Health or related field required
Master's degree Health Care Administration, Public Health or related field preferred
Experience
5-7 years Experience in a health care setting with preference given to Medicaid and Medicare Plans required
5-7 years Leadership experience in a Senior Manager or Director role preferred
Knowledge, Skills, and Abilities
Deep experience with specialized provider types, such as behavioral health is preferred as identified by the health plan (MFC DC or MFC MD).
Strong working knowledge of health care and provide billing regulations related to payer reimbursement policies, specifically with CMS sponsored plans.
Must possess excellent organizational skills, including the ability to prioritize multiple tasks and perform them accurately and simultaneously.
Ability to work with minimal supervision, guidance and direction.
Must be proficient with MS Office (Word, Excel, PowerPoint and Outlook).
Proficient knowledge of Medicaid, Medicare and other third party payer requirements pertaining to E2E functions including claims, service, enrollment, documentation, coding, billing and reimbursement.
Excellent verbal and written communication skills.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Ability to establish and maintain positive and effective work relationships with members, providers, vendors and co-workers
Demonstrated knowledge of and skill in data collection, analysis and/or interpretation of provider claims data, enrollment data and coding and configuration methodologies.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
Strong emphasis on teamwork -
our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
Strategic focus on equity, inclusion, & diversity -
we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
Comprehensive total rewards package -
including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
More career opportunities closer to home -
as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.
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