Responsible for the implementation of all Medicare Advantage and Medicare Part D activities and programs across a market in support of the Chief Medicare Officer. Provides guidance and consultation for new product start-up, program design and regulatory compliance.
Directs operational functions of Medicare products across a market.
Responsible for the oversight and execution of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials and group setup.
Facilitates internal and external Medicare audit activity including CMS and operation integrity audits.
Coordinates file pulls, data requests, universe development and supporting documentation.
Maintains an awareness of trends, developments and governmental regulations in Medicare and managed health care organizations.
Responsible for Medicare product design features, integration schedule and operational readiness in a new product start-up environment.
Participates on various committees to represent the Medicare Department including NCQA, Internal Research, UM/QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, migration and etc.
Leads member retention activities, including development of outreach materials, design/implementation of outreach programs both directly and in coordination with corporate member retention team and development of talking points/educational pieces about market specific issues.
Monitors sales and marketing activities to assure adherence to Federal and State regulations.
Guides, consults and leads product implementation and strategic focus for Medicare Part D and Medicare Advantage. Coordinates strategies and recommends policy positions with senior management regarding legislative issues and regulatory with a key support function in program and project management in support of Medicare Advantage and Medicare Part D, including Stars, Revenue Management, Quality and Network concerns.
Recruits, develops and motivates staff.
Initiates and communicates a variety of personnel actions, including employment, termination, performance reviews, salary reviews and disciplinary actions.
Performs other duties as required.
Significant (7+ years) experience in Medicare operations and/or Medicare compliance functions.
Excellent communication, interpersonal and executive presentation skills.
Strong business & financial acumen with experience in managing complex budgets.
Proven leadership and consulting skills.
Able to effectively coordinate multiple projects and programs in a matrix environment and work independently.
Familiarity with regulations and statutes impacting the managed care environment.
Ability to perform analysis and legal research to identify and clarify issues.
Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications.
Masters degree preferred.
Bachelor's degree desired or equivalent work experience.
There is a strong preference for candidates in Chicago but will consider candidates from surrounding cities such as Kansas City, Cincinnati, Milwaukee, St. Louis, Indianapolis, Detroit and Louisville.
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Aetna is an Equal Opportunity, Affirmative Action Employer