Sr Director, MA Governance and Oversight

Medicare Advantage Operations Manager

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose :

Responsible for ensuring the integrity and effectiveness of BCBSSC's Medicare Advantage Plans. Develop and implement improvement strategies, conduct process reviews, collaborate operational teams to remediate issues and implement new guidance. Analyze data and trends to identify opportunities for improving the quality and effectiveness of Medicare Advantage plans and ensure compliance with CMS requirements and provide guidance on new and existing regulatory requirements. Requires a high degree of communication with stakeholders, including operations, compliance and legal. Teaching and monitoring key performance metrics internally and with our vendor FDRs. Participate in the development of policies, procedures and workflows. Act as a subject matter expert on Medicare Advantage and provide guidance and support all constituents that provide services to Medicare Advantage. Communicate with external stakeholders, such as government agencies and accrediting bodies, to ensure compliance and maintain positive relationships. Embrace a culture of problem identification and remediation.

What You'll Do :

Develops strategies and establishes operation policies consistent with contract requirements. Evaluates the results of overall operations regularly, lead development and implementation of needed operational efficiencies. Identify and develop programs to increase membership growth and profitability. Responsible for oversight of subcontractors' quality.

Oversee government audits and regular government on sites. Develop, direct, and maintain contractor and state regulatory relationships. Responsible for financial and quality goals.

Lead interdepartmental team comprised of Sr. Leadership to develop strategies and identify corporate resources to leverage. Identify and partner with appropriate internal and community organizations to strengthen brand, create market awareness and increase membership.

Mentor and coach staff to ensure implementation of product strategies and efficient plan operations. Responsible for employee hiring, training and development, addressing performance issues, resource planning and strategic objectives. Promote professional growth. Provide guidance and leadership in staff and resource management, team building and training to ensure organizational effectiveness.

Oversees the development and implementation of new product benefits and their execution. Develops and oversees an oversight program that meets the requirements as outlined by the contract (s).

Creates / Coordinates / submits responses to applicable business or government entities. Reviews all memos / transmittals to ascertain appropriate action required and subsequently communicates required action. Monitors resolution activities, creates responses to applicable business or government entities.

To Qualify For This Position, You'll Need The Following :

Required Education : Bachelor's in a job-related field.

Required Work Experience : 10+ years-of job-related operations oversight experience (including marketing, medical management, provider relations, quality, program integrity, compliance, claims, customer service, behavioral health, and / or finance) in an insurance, healthcare, or similarly complex industry including either 5 years in a management role OR 5 years of equivalent military experience in grade E4 or above.

Required Skills and Abilities : Strong interpersonal skills and the ability to work professionally with persons at all levels to maintain effective working relationships. Ability to communicate clearly and effectively in oral and written form; Strong presentation, negotiation and organization skills. Excellent analytical or critical thinking and problem-solving capabilities. Ability to think strategically and lead operational improvements. Ability to make sound decisions. Ability to exercise confidentiality and discretion. Strong knowledge of relevant compliance regulations associated with operations and contract responsibilities.

Required Software and Other Tools : Microsoft Office.

We Prefer That You Have the Following :

Master's degree in business, Healthcare, Accounting, Finance, or other job-related field.

Extensive knowledge of CMS guidance and Medicare Advantage.

Advanced training in healthcare compliance or Medicare Advantage.

10 years' experience in Medicare Advantage.

Critical thinking skills.

Our Comprehensive Benefits Package Includes The Following : We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

Subsidized health plans, dental and vision coverage

401k retirement savings plan with company match

Life Insurance

Paid Time Off (PTO)

On-site cafeterias and fitness centers in major locations

Education Assistance

Service Recognition

National discounts to movies, theaters, zoos, theme parks and more.

What We Can Do for You : We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next : After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement : BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information .

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