Summary

Oversees and supports all Medicaid & Medicare Part D operational tasks in compliance with applicable federal, state and local laws, rules, regulations and internal policies and procedures. Performs Account Management activities related to assigned Medicare and Medicaid clients.

Essential Tasks and Responsibilities

Operations

• Serves as a subject matter expert in all CMS guidelines and processes for both government programs: Medicare & Medicaid.
• Supports RFI and RFP submissions as well as pre-sales opportunities for Medicare Part D and Managed Medicaid clients.
• Collaborates in the development and optimization of operational workflows to integrate Medicare & Medicare requirements.
• Responsible for maintaining oversight of all informative documents released by CMS and the claims processor including but not limited to the following:
• o Memos, call letters and regulatory guidance on HPMS, CMS communications and claims processor’s biweekly newsletters.
• o Submissions modules and manuals available on HPMS as applicable to the PBM.
• o Regulatory and guidance documents available on the CMS website. As a result, pertinent information should be communicated to all necessary parties within the organization.
• Responsible for overseeing/managing the PDE full process in coordination with clients.
• Responsible for overseeing/ensuring that the operational areas are performed according to the Medicare Prescription Drug Benefit Manual:
• Monitors compliance of, but not limited to CMS Reporting Requirements as agreed with clients including: Formulary submissions, Pricing tools, Pharmacy network, EOB files, PDE, FIR, Data Validation, among others.
• Oversees new plans being implemented for upcoming calendar years in coordination with internal departments.
• Supports operational areas during CMS auditing processes.
• Ensures processes are in place for claims processing, accurate timely and complete submissions to CMS and all compliance with CMS requirements as applicable (transition, formulary, P&T attestations).
• Provides support to EOB and FIR in order to report to client jointly with IT and Operations Departments.
• Operational liaison between MC-Rx and their Medicare clients.
• Liaison between MC-Rx PR and US Mainland, and the claims processor for Med D.
• Provides oversight and support to a team responding to client and government audit needs. Provides guidance, compliance, operational expertise and issue management support to the team managing audit support activities.

U.S. Clients

• Manages daily operations as they apply to clients in the U.S. mainland.
• Oversees the delivery of periodic reporting packages.
• Leads periodic meetings and conference calls with U.S. clients.
• Ensures cross functional team is performing according to CMS guidelines, internal processes and procedures, and contractual agreements.

Education/Experience

• Bachelor’s Degree in Science, Business Administration, Health or 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, Power Point, 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.