Operations Planning Specialist (PDP Oversight & Monitoring)

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Job Summary

BASIC FUNCTION
This position will be accountable to support oversight and monitoring of individual Prescription Drug Plan (PDP) Enrollment & Premium Billing operations, compliance with CMS (Centers for Medicare & Medicaid Services) requirements, mock audit support and CMS plan audits support. Will be responsible for oversight of Enrollment & Premium Billing operations to identify non-adherence to established processes as well as identify improvement opportunities, reporting results through ongoing audit spreadsheets, dashboards and scorecards. This role includes vendor oversight and collaboration as well as coordination with other internal partners and other lines of business for consistent processes across operations.

NOTE: this is classified as a REMOTE opportunity and candidates must reside in and be authorized to work in a state where HCSC is approved to employ remote workers. Applicants residing in restricted states (i.e. AK, CA, HI, NY) are not eligible for employment consideration for this position.

JOB REQUIREMENTS

• Bachelor's Degree or equivalent experience.
• 3-4 years of relevant Medicare (Part D and/or Part C) or other government program experience in eligibility, premium billing or healthcare operations.
• Proficiency with Microsoft Word, Excel, Outlook, PowerPoint.
• Must be self-motivated and possess the competencies required to work in a fast-paced and heavily matrixed environment
• Ability to perform responsibilities independently as well as an effective team member
• Excellent conceptual and analytical skills with the ability to identify linkage between interfacing systems and processes, identify issues and manage/execute solutions to resolution.
• Strong problem solving skills and detail orientation.
• Ability to analyze situations and is comfortable dealing with ambiguity.
• Capacity to learn process and product information quickly and efficiently.
• Excellent organizational and written/verbal communication skills.

PREFERRED QUALIFICATIONS

• Knowledge of advanced Excel, report writing, and analysis activities.
• Enrollment and eligibility experience and process improvement is a plus.
• Medicare Advantage or Part D experience.

~ KEY RESPONSIBILITIES ~

• Support daily oversight and monitoring of PDP Enrollment & Premium Billing operations with the vendor, internal and external partners. Includes BPO vendor, Pharmacy Claim vendor (Express Scripts), and internal HCSC Business and matrix partners.
• Perform ongoing review and interpretation of new and existing CMS requirements to ensure processes are compliant with CMS.
• Monitor operational metrics, critical volumes, and daily inventory to proactively identify potential issues.
• Review Service Level Agreement (SLA) on a monthly basis and work with vendor/matrix partners to address any issues impacting enrollment and billing operations
• Manage weekly monitoring activities; pulling samples, tracking results and evidence of corrective action to support CPE audits, and prepare results reporting for leadership.
• Perform focused monitoring/audits post deployment of changes to operational processes.
• Participate in and actively support all internal, external, and CMS audit activities by quality reviewing universes, samples and all supporting documentation.
• Identify and articulate trends and issues found in monitoring and work with business partners and vendor for remediation and/or process improvements.
• Support additional duties and projects based on business needs such as AEP and 1/1 Readiness activities related to enrollment and billing.
• Support Annual review of vendor policy & procedures to ensure processes are up to date and current with CMS guidance and Company Business policies.

Are you being referred to one of our roles? If so, ask your connection at HCSC about our Employee Referral process!

Pay Transparency Statement:

At Health Care Service Corporation, you will be part of an organization committed to offering meaningful benefits to our employees to support their life outside of work. From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for employees. Learn more about our benefit offerings by visiting .

The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

HCSC Employment Statement:

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Base Pay Range

$41,700.00 - $92,800.00

Exact compensation may vary based on skills, experience, and location.

Originally posted on Himalayas