The Medicare Operations Manager oversees to oversee claims processing, provider disputes, call center, and analytical reports for the Medicare line of business. Collaborates with Third Party Administrators, vendors and providers to ensure operations run smoothly and effectively. Assists with the day-to-day operations of a new line of business and implementing CMS and Medicare policies and procedures. Adheres to fraud and abuse prevention and/or detection policies and programs according to regulatory requirements.
This position is exempt from Career Service under the CCH Personnel Rules
Assists on oversight of claims function, call center metrics, billing guidelines, provider disputes, and other day-to-day operations and integration of Medicare initiatives into operational processes
Collaborates with MoreCare, a new Medicare partner, and Third Party Administrator to ensure all operations run seemingly
Manages HPMS and CMS memos related to all operations
Implements enhanced capabilities for accountability and integrity of daily operations Plans and directs all aspects of the operations for assigned products and programs
Measures key performance indicators to analyze the success of program implementation
Facilitates operational oversight for product and program functions and identifies opportunities for improving efficiency and cost reduction
Ensures operational processes and policies are compliant with corporate standards and applicable local, state and federal regulations
Provides resolutions to managed care contractual issues pertaining to contract interpretation and coding with payers
Adheres to confidentiality standards and HIPAA compliance programs
Adheres to fraud and abuse prevention and/or detection policies and programs according to regulatory requirements
Performs other duties as assigned
Reports to the Senior Manager of Operations, Health Plan Services
Bachelor's degree from an accredited college or university is required (Must provide official transcripts at time of interview)
Three (3) years of health plan experience in Medicare or other government lines of business or health plan services is required
Two (2) years of experience in a Medicare Managed Care role with direct product/program experience in claims, contract compliance, payment methodology, provider network and day to day operations is required
Intermediate proficiency with Microsoft Office Suite (Access, Excel, PowerPoint and Word) is required
Must be able to travel throughout Cook County is required
Master's degree from an accredited college or university is preferred
KNOWLEDGE, SKILLS, ABILITIES AND OTHER CHARACTERISTICS
Knowledge of the principles of Medicare principles and management practices
Knowledge and familiarity with Medicare insurance payment systems, inpatient and outpatient reimbursement, such as Diagnosis-related group (DRG) reimbursement and/or Enhanced Ambulatory Patient Groupings (EAPG) reimbursement structures
Knowledge of Microsoft Office Suite (Access, Excel, PowerPoint and Word)
Knowledge and understanding of implementation, startups and operationalizing Medicare programs
Excellent interpersonal, verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups
Must be able to travel to work sites throughout Cook County including community agencies, network providers, government and other agency offices
Excellent program development, management and leadership skills
Demonstrates good computer and typing skills
Demonstrate good phone and email etiquette skills with strong response times
Demonstrate analytical and organizational, problem-solving, critical thinking and conflict management/resolution skills
Demonstrate attention to detail, accuracy and precision to support research and presentation skills
Ability to prioritize, plan and organize projects and tasks
Ability to multi-task and meet deadlines in a fast paced and stressful environment
Ability to maintain a professional demeanor and composure when challenged
Ability to function autonomously and as a team member in a multidisciplinary team
Ability to train by presenting concepts and demonstrating tasks
Ability to perform accurate and reliable mathematical calculations to support reimbursement analysis and measure financial performance
Ability to work flexible hours
Must be able to travel to work sites throughout Cook County
When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service.
To take advantage of this preference a Veteran must:
Meet the minimum qualifications for the position.
Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, "Are you a Military Veteran?"
Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list an Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable.
A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.
If items are not attached, you will not be eligible for Veteran Preference
VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER'S LICENSE AT TIME OF INTERVIEW
MUST MEET REQUIRED QUALIFICATIONS AT TIME OF APPLICATION
Medical, Dental, and Vision Coverage
Basic Term Life Insurance
Deferred Compensation Program
Paid Holidays, Vacation, and Sick Time
You may also qualify for the Public Service Loan Forgiveness Program (PSLF)
*Degrees awarded outside the United States with the exception of those awarded in one of the United States' territories and Canada must be credentialed by an approved U.S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents must be presented at time of interview.
*Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
*CCHHS is strictly prohibited from conditioning, basing or knowinglyprejudicing or affecting any term or aspect of County employment or hiring uponor because of any political reason or factor.
COOK COUNTY HEALTH AND HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER
ABOUT COOK COUNTY HEALTH (CCH)
The Cook County Health’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCH is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCH is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, ...collaborative health plan and enhancing the patient experience.
COOK COUNTY HEALTH IS AN EQUAL OPPORTUNITY EMPLOYER