Job Details

The Director of Health Plan Operations will be responsible for identifying, developing, implementing, monitoring and managing all financial and business-related operations, that contribute to successful operation and support continued growth. The Director will be responsible for building, scaling, and continuously optimizing core operational functions, including—but not limited to—third-party administrator (TPA) oversight (claims), utilization management, Part D oversight, and provider network administration.

Essential Functions

• Direct and oversee the day-to-day business and health plan operations of the PACE programs, including, but not limited to, insurance eligibility (Medicare/Medicaid), claims processing, fiscal soundness, and vendor contracts to ensure alignment with strategic goals
• Serve as the accountable leader for PACE Health Plan Operations functions
• Develop and maintains Standard Operating Policies and Procedures for all operational functions of the PACE programs to maintain compliance, efficiency and scalability
• Ensure adherence to all state and federal regulations governing PACE operations. This requires coordination and collaboration with the Pace Medical and Administrative teams, Compliance Officer, Finance team, the PBM, and other various stakeholders
• Manage and provide oversight to the Third-Party Administrator (TPA), the Pharmacy Benefit Manager (PBM), and other key vendors, including vendor credentialing, management, and receivables/payables

• Lead government relations with respect to health plan operations and lead regulatory audits (e.g., PACE 1/3rd financial audit, Part D audits, enrollment data verification, and other health plan related audits

• Develop and maintain effective monitoring programs for claims processing, enrollment reconciliation, Medicare Part D, RAPS, and Encounter Data submissions

• Stay current on regulations and policies impacting the PACE programs, health plan operations, and our compliance program and share that knowledge across the organization

• Design and support reporting needed by the operations teams (e.g., Quality, Risk Adjustment, Utilization)

• Manage enrollment data and data systems including data transfers and the development and management of systems to meet PACE programmatic requirements

• Lead provider network administration, including strategic support for negotiations, managing our catalog of contracts, properly loading all contracts into required systems/vendors, and managing the provider manual

• Oversee and directs timely reviews and monitoring of vendor compliance with contractual standards and with CMS regulations

• Direct the negotiation, drafting, and execution of vendor contracts 

• Oversee and direct claim processing operations to ensure timely and accurate payments according to vendor contracts and CMS guidelines

• Oversee and reconcile enrollment and eligibility operations to ensure accurate membership and capitation

• Analyze key performance indicators (KPIs) to drive data-informed decisions, that support operational needs, and to optimize organizational performance

• Recruit and maintain a high-quality provider network of specialists and providers as required by PACE CMS regulations

• Direct compilation of all required data for analysis and quality review prior to submission to CMS for Part D monthly, quarterly, and annual reporting, including but not limited to: Coordination of Benefits (COB), Prescription Drug Events (PDE), etc.

• Monitor reporting submissions to regulatory agencies. Ensures submissions of various regulatory and/or financial reports and data as required (including HPMS) in coordination with the Executive Director(s), Finance Team, Compliance Officer, and others

• Responds to monthly financial variance report provided by corporate accounting and tracks trends in fiscal data month to month as well as year over year. Makes recommendations regarding any budget variances

• Actively participate in various governance committees including but not limited to Utilization Management, Compliance, etc.

• In partnership with the Organization’s Finance Department, facilitate the Medicare Part D bid process, including serving as a contact for actuaries in bid-development.

• Coordinate with legal, risk, and compliance teams to ensure that risk management strategies comply with CMS regulations and best practices Implement and monitor risk management strategies to mitigate operational vulnerabilities

• Collaborate with PACE Directors to identify, develop, and implement opportunities for process improvement, scalability, and efficiency across all departments

• Collaborate with PACE executive and PACE clinical leadership to align operational objectives with financial and participant-centered goals

• Continuously seek improvements to processes and systems across functions as the size and complexity of PACE grows

• Continuously assess and improve the department's performance by designing operational processes, monitoring performance through data, analyzing the data, implementing sustainable performance improvement, and participating in multi-disciplinary inter-departmental PI activities.

• Ensure the financial viability/continued growth of the program through management of the insurance practices and compliance with federal and state regulations, as well as managing business relationships with all contracted providers and supporting the State and Federal relationships surrounding the PACE program.

• Participate in strategic direction alongside clinical operations director of the PACE programs.

• Participate in annual forecast including volumes, revenues, FTEs, salary, supply and other expenses in accordance with system profitability targets.

• Report financial and utilization metrics to evaluate, celebrate or improve the financial performance of the PACE programs

• Assist with the preparation of annual budgets in partnership with PACE Leaders and Finance Team

• Assures consistency of Business Plans across all PACE programs

Experience/Education

Master's in Business Administration, Health Administration, or related; or equivalent experience - Required

• 5 years Administration of PACE, healthcare, or Medicare/Medicaid insurance, with a demonstrated record of progressive professional leadership responsibility. - Required
• 7 years Administration of PACE, healthcare, or Medicare/Medicaid insurance, with a demonstrated record of progressive professional leadership responsibility. - Preferred
• 1 year work in a program serving frail/elderly population - Required
• 3 years’ work in a program serving frail/elderly population - Preferred
• Knowledge of Medicare, Medicaid and insurance billing - Required
• Good understanding of all aspects of operations of PACE model, health plan operations or managed care models.
• Proficient in the development of business plans, financial models, and health care financing.
• Excellent oral and written communication skills, including proficiency in Excel, Word and other software necessary to develop extensive feasibility analysis.
• Demonstrated experience in coordinating the planning, directing and evaluation of patient care, effective communication and conflict resolution skills

Empath Health values diversity as it strengthens our community and care. We embrace the diversity of cultures, thoughts, beliefs and traditions of our employees, volunteers and people we are honored to serve across our network. Our diverse staff reflects our community and each day, we work to be respectful, sensitive and competent with each other and those in our care. In every journey, we are dedicated to achieving comfort, dignity and exceptional care. Those of all backgrounds are welcome and encouraged to apply with us or seek our care and services.

Our commitment to patient, client, staff and volunteer safety is a cornerstone of a High Reliability Organization with a focus on zero harm. Participation in the seasonal influenza is a condition of employment and a requirement for all Empath Health employees.

Providing compassionate, full life care is an honor we take seriously at Empath Health. Join our team and make a positive impact in the community!