Director II Medicare Operations
Elevance Health

Job Info

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Director II Medicare Operations

Location: This position will work a hybrid model (remote and office). The ideal candidate will must live within 50 miles of one of our Elevance Health PulsePoint locations.

National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.

The Director II Medicare Operations is responsible for Claims, Medical Policy/Review, Grievance & Appeals, Overpayment Recoveries, and Medicare Secondary Payer for National Government Services (NGS) a contractor for the Center for Medicare and Medicaid Services.

How you will make an impact:

• Responsible for Part A/B Claims processing, pre-pay and post-pay medical review activities, development and reconsideration of medical review policies for Part A/B, and Regional Home Health and Hospice Intermediary (RHHI); and the analysis of data to review the impact of medical policy application as well ascertain adherence to the policies.
  
• Directs the activities of all Part A, B, and DME re-determinations; Administrative Law Judge (ALJ) appeals; clerical error re-openings; and the investigation and recoupment of all claim overpayments and subrogation of those claims where Medicare should be the secondary payer.
  
• Responsible for data mining & reporting, identifying opportunities for improvement and consistency of decisions, and the CMS quality and timeliness standards.
  
• Has frequent and regular contact with various representatives of CMS and with the contractors for whom NGS is the subcontractor.
  
• Participates in RFP activities, such as responding to bids, writing detailed specifications, and delivering oral presentations for contract procurement.
  
• Drives innovation throughout the Medical Review, Appeals, Overpayment Recovery, and Medicare Secondary Payer units to reduce the overall costs associated with performing the CMS statement of Work requirements.
  
• Hires, trains, coaches, counsels, and evaluates performance of direct reports.
  
• Travels to worksite and other locations as necessary.
  

Minimum Requirements:

• Requires a BA /BS in a related field and minimum of 10 years professional/leadership experience with CMS including strategic planning, project management, Medicare or related healthcare insurance or medical policy field, minimum of 3 years management experience; or any combination of education and experience, which would provide an equivalent background.
  
• This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.
  

Preferred Skills, Capabilities, and Experiences:

• RN active license.
  
• Familiar with Medicare Fee for service Clinical Appeals process.
  

If this job is assigned to any Government Business Division entity, the applicant and incumbent fall under a 'sensitive position' work designation and may be subject to additional requirements beyond those associates outside Government Business Divisions. Requirements include but are not limited to more stringent and frequent background checks and/or government clearances, segregation of duties principles, role specific training, monitoring of daily job functions, and sensitive data handling instructions. Associates in these jobs must follow the specific policies, procedures, guidelines, etc. as stated by the Government Business Division in which they are employed.

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