Under minimal supervision, provides leadership and management of the day-to-day operations of the Medicaid Choice, CHP+ and Medicare Choice/Select programs, including oversight of medical benefits and administrative costs, negotiating and managing rates and contracts for Medicaid, CHP+ and Medicare Plans, health quality outcomes, member satisfaction, enrollment and growth, data integrity analysis, Prescription Drug Events (PDE), risk adjustment methodologies, plan benefit design, premium billing, and managing staff. Directs the Medicaid Choice, CHP+ and Medicare Choice/Select programs in accordance with federal, state and local laws and regulations. Evaluates current industry trends to develop short-term and long-term goals and opportunities for new business development. Maintains an effective relationship with the State of Colorado, Colorado Department of Health Care Policy & Financing ("HCPF") and Centers for Medicare and Medicaid Services ("CMS"). Influences potential rule changes with regulatory authorities and oversees implementation of changes to benefits, regulations, and requirements.
1. Leads Risk Adjustment, Medicare Stars Program and/or other Quality Rating, and Enrollment teams to ensure project goals are met and staff developments are accomplished timely, efficiently, and effectively. * Determines work procedures and expedites workflow; develops and updates department policies and procedures; assigns duties and reviews work; prepares necessary and required reports to management. Ensures that enrollment processes are in compliance with all regulatory entities, federal, state, and local government.* Maintains adequate dialogue with staff and maintains monthly staff meetings. Provides resources, tools, and training needed to be successful and maintain performance levels and goals.* Monitors, evaluates, appraises employee's activities and ensures all goals are met in accordance with regulatory and Denver Health's policies and procedures.
2. Works with the Director of Insurance Products to coordinate all aspects of the CMS and State Bid Processes, including, but not limited to, contractual terms, benefit design, program/system implementation, business development, strategic planning, regulatory requirements, new opportunities, and other business needs as appropriate.
3. With the Director of Insurance Products, leads and directs effective strategic and operational planning for the organization.* Demonstrates the ability to assess data/system applications reflecting the Plan's services functions and performance. Uses advanced analytical, technical, and conceptual skills to develop system solutions for operational metrics including: enrollment, risk adjustment, quality and member satisfaction outcomes and other regulatory processing requirements.* Assures data integrity through ongoing assessments, development, and oversight of databases and applications. Resolves operational and unforeseen procedural problems, and addresses other concerns relative to application implementation, regulatory compliance, and hospital best practices as directed or as necessary.* Quickly identifies and communicates problems with appropriate communication to all affected areas and staff.* Coordinates across the organization to create effective resolutions and implement an appropriate solution utilizing the right resources.
4. Works closely with the Medical Plan's Compliance Department to ensure the Medicare and Medicaid Plans' operational performance meets or exceeds regulatory requirements including, but not limited to, operation al processes, internal auditing and monitoring, external audits, policies and procedures creation, maintenance and reporting.
5. Prepares and presents monthly, quarterly, annual and ad-hoc reports upon request. Develops objectives, policies, procedures, and processes for the department.
1. Seven years' experience in health care, with emphasis on health plan administration and/or state and federal health care plan management required.
2. One year lead or supervisory experience required.
3. Knowledge of Medicare, Medicaid, and CHP+ Plans and the associated state and federal regulatory requirements.
4. Strong management experience and demonstrated success in managing a team of professionals.
Knowledge, Skills and Abilities
1. Able to identify resolutions and implement appropriate solutions utilizing the correct resources for Medicare and/or Medicaid and CHP+. Significant experience and knowledge of Medicare and Medicaid health plan regulatory requirements is essential. Able to identify, review and update existing documentation to comply with new CMS policies and procedures. Knowledge of the Medical Plan and Denver Health's state, local and federal insurance programs is highly desirable.
2. Evaluates and ensures enrollment applications meet established CMS operational standards. Analyzes enrollment processes and makes appropriate recommendations regarding system modifications and new applications necessary to meet regulatory and industry changes.
3. Demonstrates initiative, exercises good judgment, exhibits strong service orientation, and has the ability to achieve results through others.
4. Able to manage a team of professionals. Has excellent interpersonal and writing skills; can interact professionally with regulators, employees, and senior leaders. Ability to multi-task, prioritize, delegate, create, and implement standardized processes and operational workflow.
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver's 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado's primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an equal opportunity employer (EOE).
"Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class."
Internal Number: 3438
About Denver Health
Take your career to the next level at Denver Health, where we offer a robust benefits package and endless opportunities for growth. Denver Health is a nationally-ranked, locally-trusted, premier healthcare institution located in the heart of Denver, Colorado.Twenty-five percent of all Denver residents, or approximately 150,000 individuals, receive their health care here. We are known as an integrated health care system that encompasses multidisciplinary academic specialties, a community health system, a level I adult trauma center, pediatric emergency and urgent care center home to Denver Public Health and many of the nation’s leaders in medicine.