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Health New England
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  • Medicare Program Dev. and Implementation Lead  

    - Springfield

    Job DescriptionJob DescriptionPurposeUnder the direction of the Director, the Medicare Program Development and Implementation Lead serves as the subject matter expert (SME) on Medicare programmatic regulations for HNE and will support the Director in ensuring operational effectiveness, efficiency & compliance across all functional areas. The Medicare Program Development and Implementation Lead will partner with operational teams to implement new products, benefits & regulatory requirements, assisting in product development, monitoring the market, and analyzing its trends to support Health New England’s growth initiatives. The Medicare Program Development and Implementation Lead acts as a consultant and collaborates with the Medicare, Compliance and other business leaders. The Medicare Program Development and Implementation Lead will model and validate the impact of new, current products, and programmatic changes as well as work with the financial optimization workgroup to assess for cost savings and revenue opportunities for HNE.Accountabilities Act as a consultant and collaborate with the Medicare, Compliance and other business leadersModel and validate the impact of new, current products, and programmatic changes as well as work with the financial optimization workgroup to assess for cost savings and revenue opportunitiesServes as the company’s research specialist regarding Medicare methodologies and policiesProvides Medicare subject matter expertise and assist in the implementation of programmatic changes based on regulatory guidance (support and responds to all program changes and updates)Analyzes Medicare market trends, examines competitor benefits and understand new market opportunities through tools such as TEG and DEFT research reportsPartner with operational departments including Claims, Call Center, Finance, Enrollment, Vendor Management, and Medical Management to design processes/procedures ensuring effective & efficient operations and to determine the impact of implementing Medicare relevant productsIdentify & integrate operational best practices, partnering with key departments to optimize processes across the organization such as benefits administration, marketing & communications, and customer experienceWork closely with Compliance and Regulatory teams to confirm adherence to CMS regulationsPartner with internal & external stakeholders on key strategic, regulatory & operational projectsPartner with Risk Adjustment & Analytics teams to ensure complete & successful RAPS/EDPS submissions including enrollment reporting when neededDevelop and monitor operational dashboards and KPI's to ensure operational effectiveness & compliancePerform root cause analysis of identified issues, in partnership with other departments as necessary, to identify opportunities for improvement, and develop innovative solutionsDevelops summarized reporting for leadership executive team review utilizing aggregate data and information to assist decisions in the financial optimization work-groupMonitors both CMS regulations, lists, server’s and other sources to identify existing payment practice and proposed changesServes as the department’s project lead to drive changes as a result of regulatory changes, such as proposed and final Medicare regulations and Medicare Provider Manual updatesSupports the business partners to accurately implement software updates that impact Medicare toolsAssists in operationalizing strategic partnership by providing regulatory and programmatic supportResponsible for requirements development, follow through and testing support on end-to-end implementation of new systems that impact Medicare line of businessParticipates in various work groups and committees to support product - growth initiatives and provides input into processes and workflows that support timely system updateAttends state public hearings to gain insight on proposed regulatory changesCollaborates with stakeholder departments to financial size and estimate the impact of financially impactful changes to methodologies Conducts research on benefit and product enhancements and works with stakeholders on cost/benefit analysis considering the aggregate product and benefit changes for evaluationValidates Benefit Package entry into the CMS systemAudit CoordinationLeads assigned audits and works with cross-functional departments to gather and deliver the necessary data to fulfill all audit requirements; including managing tracking grids, scheduling resources, and providing regular progress update reports to managementProvide oversight of plan & vendor operations as they relate to the Medicare line of business, aligning outcomes to strategic goals & requirementsResponsible to assist with the annual Medicare Bid submission ensuring Plan Benefit accuracy while working with internal departments to create competitive productLead vendor and internal implementations for updated medical benefits and any needed changesOversee Medicare monitoring including reviewing daily, weekly, and monthly reporting program elections and progress, enrollment and CMS submissions for accuracy and reconciliationCo-Lead Annual Enrollment Period processes ensuring education and alignment with internal departmentsOversee the accuracy of regulatory materials including the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) Ensure successful & complete submission of Medicare Part C & D reportingPartner with Compliance team to develop & follow up on action plans to improve effectiveness as requiredMonitor reports to track operational effectivenessEnsure Medicare vendors adhere to Service Level AgreementsAd-hoc projects as assigned Job Title: Medicare Program Dev. and Implementation Lead/Medicare Advantage Reporting Relationships (Job Titles only)Manager:(include secondary Manager if applicable)Director, Medicare Program DevelopmentDirect Reports:Shared Reports (solid/dotted if applicable): External/Internal ContactsInternalMost all HNE departmentsExternalCMSCommonwealth of MAMillimanNumber of external vendorsEducation / Experience / Other Information (include only those that are specific to the role)Bachelor’s degree in a related field and a minimum of 5+ years’ of relevant experience, or the equivalent combination of training and experience, in a fast paced, managed healthcare environment is requiredMinimum of 5 years of experience and advanced knowledge of Medicare requirements, products, and bid pricing Deep understanding of the government standards and product developmentDemonstrated success working cross functionally managing complex initiatives and deliverables Demonstrated knowledge and solid understanding of MedicareAbility to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solveFlexible, highly motivated, self-starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervisionStrong analytical skills coupled with good communication skills, both oral and written, ability to interact well with others at all management levelsDemonstrated proficiency using MS tools, including excel with an interest or skill set to leverage reporting tools for analytical purposesStrong organizational skills and strong internal customer/business partnership/service skillsStrong background in working with technical teams to implement complex business requirements, subsequent testing, and workflow closureValid driver's license required Working ConditionsNon-standard hours are a common occurrence. Occasional travel within and outside of HNE’s business areas.Opportunity for Remote work

  • Senior Project Manager  

    - Springfield

    Job DescriptionJob DescriptionAre you seeking a company committed to offering a genuine, warm human experience, no matter what?Health New England, a non-profit health plan serving members in western Massachusetts, is seeking a Senior Project Manager. This position is responsible for managing large complex IT projects from the initial evaluation phase through project completion. The ideal candidate will have five (5) years of experience, ideally in health plan and/or health insurance and will possess excellent project management and facilitation skills; analytical, organizational, and interpersonal skills; Waterfall experience; and written and verbal communication skills.Join Health New England where you will have the opportunity to be your best self every day!
    SUMMARY: The Sr Project Manager is responsible for managing large complex IT projects from the initial evaluation phase through project completion. This includes meeting project objectives within established timelines, budget, and managing associated risks. The Senior Project Manager may work with consultants, internal & external customers, subject matter experts, and cross functional teams. The incumbent will provide periodic updates and reports to ELT and the Director’s Team on the project(s) progress. These projects have a major impact on HNE being able to effectively and efficiently perform its business operations. Project Management - 80%Develops detailed project work plans and manages scope, time, cost and resources to implement solutions to support the company's business needsWorks with consultants, subject matter experts, internal and external customers to address issues and identify solutions; manage the project objectives and target datesEffectively uses project management tools to insure successful and timely project completionProvides risk management and quality management; addresses and resolves issues; facilitates change and communication to ensure successful integration Impact Assessment and Solution Recommendation – 20%Evaluates IT impact of newly identified problems or opportunitiesIdentifies affected departments or systems and estimates cost for analysis and potential resolution by engaging necessary technical or business resourcesParticipates in IT project prioritization based on needs and dependenciesMakes recommendations regarding short vs. long term approaches to specific situationsMust be able to champion proposed solutions and plans to obtain commitment from stakeholdersLeads vendor evaluation process and develops cost/benefit analysis to facilitate the decision to implement a packaged vendor selection or justify in-house development MINIMUM REQUIREMENTS:Bachelor's degree in MIS or related field and a minimum of 5 years IT experience in managed health care, health insurance, or related industry; or an equivalent combination of education and experience. Demonstrated experience with effective planning, problem solving, and continuous improvement processesExperience with project management techniques such as Work Breakdown Structure, Critical Path, Gantt charts, and Use CasesExperience in Waterfall project development techniquesProficient with the Microsoft Office Suite applications (including Word, Excel, Access, Project and PowerPoint) and VisioExcellent project management and facilitation skillsExcellent analytical, organizational, and interpersonal skillsExcellent written and verbal communication skills

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