Job Description

Carrier Operations Manager

Position Summary

This position has primary responsibility for the management of Medicare Advantage PPO programs, Self-Insured products/plans, Dental, Vision, Hearing and OTC benefits. This includes interfacing with third party carriers and vendors, developing analytic reporting, and serving as a Subject Matter Expert (SME) for UAW RMBT Carrier operations. Work involves the ability to make decisions within the limits of the UAW RMBT policies and procedures relative to the UAW RMBT plans. This may include, but is not limited to eligibility, benefit coverage, claims, payment and policy interpretation. Responsible for managing internal Carrier Operations staff, including knowledge base and development.

· Under the direction of an Officer, Senior Director, or Director is accountable for an identifiable benefit, healthcare, or customer service program of the trust.

Essential Functions

1. Provides overall management and day-to-day oversight of plan operations.

2. Evaluates programs/activities designed to improve overall performance of MA plans.

3. Researches and presents opportunities for MA plan enhancements.

4. Develops and maintains benchmarking and reporting mechanisms for MA plans (e.g., cost/quality and utilization reporting dashboards).

5. Evaluates overall MA health plan performance and present reports and trend analyses

6. Monitors and tracks implementation and utilization of new programs and initiatives (including both internal and external).

7. Identifies compliance and operational efficiencies and develops "best practices" of Medicare policies and procedures.

8. Work with compliance team to review and assist in the resolution of MA compliance and regulatory issues.

9. Supports annual audit activities.

10. Leads implementation of benefit changes with plans, as needed.

11. Supports internal RFP/RFR negotiation project activities.

12. Leads/supports new vendor implementations, as required.

13. Coordinates and supervises requests for documentation from MA plans to support CMS audit activities.

14. Serves as SME for all plan (external) member communications working collaboratively with the Trust internal communications team.

15. Provides ongoing coordination with internal teams, as needed.

This list details the Trust’s assignment of essential functions to this position. Other duties or tasks may be assigned to this position. This job description is subject to change at any time.

Technical Competencies

· Strong knowledge of Medicare benefits and Medicare Advantage plans

· Clear understanding of CMS Star Ratings and CMS Call Letter for Medicare Advantage and prescription drug benefit programs

· Strong analytical and writing skills

· Strong organizational and project planning skills

· Proven negotiation skills and experience with complex contracting and vendor management situations

· Ability to develop solutions to unusual situations and unique opportunities

· Ability to articulate and present health care information to non-health care audience

· Proficient in Microsoft Office applications (Excel, Word, and PowerPoint)

Leadership Competencies

Leaders of the Trust are expected to demonstrate relevant leadership competencies as specified in the Trust’s competency definitions.

Personal Effectiveness Competencies

All employees of the Trust are expected to demonstrate relevant personal effectiveness competencies as specified in the Trust’s competency definitions.

Minimum Required Experience

· 5 – 7 years of experience directly managing a Medicare Advantage health plan

· Experience with employee / retiree benefits, health care services, health care / employee benefits consulting, or related fields

· Demonstrated vendor management experience

Education, Professional Certifications and Licensure

· Bachelor’s degree in Health Care or Business Administration required.

· Master’s degree preferred.

Working Conditions and Physical Effort

· The physical requirements of this position are typical of office work.

· Some seasonal travel required.

Job Tags

Similar Jobs