Operations Support - Medicare Advantage

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Operations Support - Medicare Advantage

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Mass Advantage is a Medicare Advantage health plan, located in Worcester, MA. We are affiliated with the largest health care system in Central Massachusetts, UMass Memorial Health.

They are the clinical partner of the University of Massachusetts Chan Medical School, with access to the latest technology, research, and clinical trials.

We are seeking an Operations Support position to assist the Operations team. This person will assist with the planning, directing, monitoring, and coordinating the functions of the Operations department for a Medicare Advantage Health Plan to include claims, vendor management, member services, enrollment, and member experience directly, indirectly, or through vendor management.

In addition, the Operations Support position will direct daily operational functions and large-scale projects to ensure the timely and accurate completion of all functions and tasks.

The Operations Support position will also direct the preparation of departmental reporting, analyze and interpret all reported information, and make recommendations to the COO based on the analysis.

Accomplishes this by performing the following duties :

• Under general supervision, coordinates and / or assists with all delegated activities to ensure compliance with state, federal, NCQA, and Mass Advantage requirements, such as performing analysis of annual due diligence audits and monitoring delegated activities.
• Coordinates annual operational audits to include scheduling audits; accurately completing delegation audit tool; reporting outcomes to management;

and required follow-up (e.g., additional mailings, obtaining signature pages, and arranging annual re-audit).

• Monitors post-audit delegated activities to ensure compliance requirements are met. Examples include tracking receipt of and monitoring quarterly / yearly reports from delegated entities and assisting with development and implementation of Corrective Action Plans as non-compliant issues are identified.
• Produces monthly scorecards to monitor compliance of Delegation Oversight activities and delegate performance metrics.
• Responsible for volume / production planning, tool development / refinement, processing of captured forms, analysis of capture rates, analysis of revenue recovered, payment process, and export of data to support applicable departments.
• Performs analysis and strategy development and implementation; obtains data, verifies validity of data, and analyzes data as required.
• Leads and directs the department toward operations, procedures, and policies which assure consistent, long-term accomplishment of overall departmental objectives.
• Supports the operational performance of claims payment accuracy, manages tracking and monitoring of open tickets and issues with vendors through completion.
• Provides regular monitoring and reporting of Key Performance Indicators (KPIs) and establishes best practice claims payment methodology based on latest CMS claims payment rules, coordinating with various staff to establish best practices across all operational areas.
• Conducts root cause analysis on systemic issues and formulates action plans to avoid incorrect payment to include review of contracts, Medicare claims payment rules, internal systems, and beneficiary impact.
• Supports written reports for State and / or Federal agencies regarding inquiries into provider disputes, non-payment of claims, complaints, or Complaint Tracking Module (CTMs).
• Prepares comprehensive reports, making recommendations to correct deficiencies and practice or process improvements.
• Identifies trends and issues across the operational environment to deliver a seamless member experience.

Requirements

Education and / or Experience

Bachelor's degree (B.A.) from a four-year college or university; or five years of related experience and / or training; or an equivalent combination of education and experience.

Other Qualifications

• At least 5 years of previous experience in Operations of a Managed Care and / or Medicare Advantage Plan preferred.
• Expert knowledge of Medicare regulations for Operational functions within a Health Plan.

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