Medicare Operation Consultant

  • Serves as subject matter expert for the implementation of all Medicare Part D and Medicare Advantage activities and programs across North Carolina, South Carolina, and Tennessee.
  • Provides guidance and support for the development of new initiatives and improvement of the Medicare Advantage product line. He/she will develop and improve workflows and operational support systems to help meet product performance goals.
  • Provides support for the Medicare Part D and Medicare Advantage operational interface to ensure tactical business goals are achieved across the organization.
  • Supports the CMS bid and application activities.

Fundamental Components
Serves as subject matter expert for the operational functions of Medicare products within an assigned market. Assists with the 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. Supports 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. Provides consultative support for Medicare product design features, integration schedule, and operational readiness in a new product start-up environment. Supports member retention activities, including development of outreach materials, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues. Monitors sales and marketing activities to assure adherence to Federal and State regulations. Performs other related duties as assigned.

  • Support development of the product strategy to drive innovative and highly competitive product offerings and services to support growth and earnings
  • Understand and synthesize marketplace trends (consumer, competitor, provider)
  • Develop strategic frameworks and analytic tools to support execution of market and competitive assessments
  • Identify and prioritize opportunities to improve competitive positioning; build the business case to drive improvements
  • Assess changes in the external environment including state and federal government; identify implications and support development of plans to address
  • Drive analysis and content development to advance strategic discussions with key business partners
  • Develop training materials for internal and external stakeholders summarizing key product features
  • Partner with corporate product team to implement and execute annual member material process
  • Serve as a liaison between the Market Sales Team and Network Contracting team to build provider network and address provider data issues

Background Experience
Able to effectively coordinate multiple projects and programs in a matrix environment and work independently. Excellent consulting and leadership skills. Familiarity with regulations and statutes impacting the managed care environment. Ability to perform analysis and legal research to identify and clarify issues. Previous experience (5-7 years) in Medicare Operations and/or Medicare compliance functions. Excellent communication, interpersonal and presentation skills. Proficiency with standard corporate software applications, including MS Word, Excel, Outlook and PowerPoint, as well as some special proprietary applications. Bachelor's degree desired or equivalent work experience.

  • Fast learner with demonstrated flexibility who adapts well to a fast-moving environment and gets things done
  • Ability to build collaborative relationships with stakeholders and diverse, cross-functional teams/organizations to develop appropriate requirements, scope and delivery timeframes, driving on-time execution
  • Strong analytical thinker with the ability to deliver high-quality work in a structured, disciplined and time-conscious manner

Bachelor's degree or equivalent experience

Percent of Travel Required
0 - 10%

Business Overview
Aetna, a CVS Health company, we are joined in a common purpose: helping people on their path to better health. We are working to transform health care through innovations that make quality care more accessible, easier to use, less expensive and patient-focused. Working together and organizing around the individual, we are pioneering a new approach to total health that puts people at the heart.

We are committed to maintaining a diverse and inclusive workplace. CVS Health is an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring or promotion based on race, ethnicity, gender, gender identity, age, disability or protected veteran status. We proudly support and encourage people with military experience (active, veterans, reservists and National Guard) as well as military spouses to apply for CVS Health job opportunities.

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