Medicare and Medicaid Operations Manager

3 weeks ago


Gainesville, Florida, United States ProCare Rx Full time

As a key member of the ProCare Rx team, the Government Programs Manager- Med Part D will oversee and support all Medicaid & Medicare Part D operational tasks in compliance with applicable federal, state and local laws, rules, regulations and internal policies and procedures.

Key Responsibilities
  • Serve as a subject matter expert in all CMS guidelines and processes for both government programs: Medicare & Medicaid.
  • Support RFI and RFP submissions as well as pre-sales opportunities for Medicare Part D and Managed Medicaid clients.
  • Collaborate in the development and optimization of operational workflows to integrate Medicare & Medicare requirements.
  • Maintain oversight of all informative documents released by CMS and the claims processor, including memos, call letters, and regulatory guidance.
  • Oversee the PDE full process in coordination with clients.
  • Ensure compliance with CMS Reporting Requirements, including formulary submissions, pricing tools, pharmacy networks, EOB files, PDE, FIR, and data validation.
  • Support operational areas during CMS auditing processes.
  • Ensure processes are in place for claims processing, accurate timely and complete submissions to CMS, and compliance with CMS requirements.
  • Provide support to EOB and FIR to report to clients jointly with IT and Operations Departments.
U.S. Clients
  • Manage daily operations as they apply to clients in the U.S. mainland.
  • Oversee the delivery of periodic reporting packages.
  • Lead periodic meetings and conference calls with U.S. clients.
  • Ensure cross-functional teams perform according to CMS guidelines, internal processes, and contractual agreements.
Requirements
  • Bachelor's Degree in Science, Business Administration, Health, or a related field.
  • Minimum of three years of experience in Medicare/Medicaid Operations/Healthcare Industry.
  • Fully Bilingual: English and Spanish language.
  • Proficient knowledge of Windows, including Word, Excel, PowerPoint, and Access.
  • In-depth understanding of laws, rules, and regulations related to healthcare corporate governance.
Skills
  • Leadership
  • Problem-solving, project management, technical, and monitoring skills
  • Ability to write clear, concise reports, business correspondence, and develop policies and procedures
  • Excellent communication skills to manage internal and external customers
  • Judgment and criterion for decision making
  • Detailed-oriented and presentation skills
  • Ability to work in a fast-paced environment while demonstrating flexibility, commitment to teamwork, and a willingness to change assignments to meet clients' needs.


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