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Medicare Business Operations Specialist

Company: Magellan Health
Location: Herriman
Posted on: October 12, 2021

Job Description:

This position supports the Medicare Part D Plan(s) to ensure operational and IT business and financial management activities are aligned with department strategies, assisting with operations reviews and special assignments to support the planning and coordination of major endeavors. This includes supporting all business management processes in partnership with the appropriate process owners including strategic and operational planning, communications, reporting, financial management, and workplace management. Demonstrates knowledge of Medicare Part D regulations and operational monitoring activities to effectively perform duties that support the Prescription Drug Plan (PDP) and Employer Group Waiver Plan’s (EGWP) compliance with CMS requirements. Manages the implementation of Medicare Part D operational policies and procedures. Responsible for tracking Medicare requirements and ensuring departments continue to meet CMS expectations to deliver optimal outcomes for beneficiaries.

  • Reviews and interprets policy and regulatory documents to identify the impact on operations. 
  • Monitors HPMS Memos/ CMS guidance for operational changes and develops timelines/work plans to implement changes.  Provides support through the planning and execution of these projects. Support may include developing business requirements, establishing deadlines, assigning resources/responsibilities and monitoring and summarizing progress of projects. Prepares reports for upper management regarding status of project.
  • Identify Medicare product benefits and prepare and manage the annual bid process and validation for the Medicare plan.  Manage multiple workgroups with all levels of management for development of the bid.  Coordinate with Legal, Actuarial, Compliance, and other operational areas.
  • Provides Medicare Part D subject matter expertise in response to day-to-day business issues.
  • Creates and executes project work plans and revises as appropriate to meet changing needs and requirements. 
  • Coordinate annual readiness checklist process for CMS submission.
  • Provide general support, collect, and prepare information and data for the facilitation of standard recurring meetings, such as tactical, strategic and operations reviews.
  • Document and track action items for centralized reporting for dashboard of operational metrics.
  • Track, review, analyze project and resource expenditures.
  • Provide support to operations roles as required.
  • Support Medicare Plan(s) in downloading and submitting data to HPMS (Health Plan Management System).
  • Ensures adherenceto CMS provided timelines and ensures timeliness and accuracy of compliance activities.
  • Reviews data to evaluate KPIs.
  • Acts as a liaison between departments to manage large-scale projects and implementations.
  • Manages day-to-day operational aspects of a project, including meeting facilitation and documentation.
  • Provides status reporting to stakeholders on a regular basis. Apprises management of issues requiring resolution in order to maintain progress on a timely basis.
  • Provide ad hoc analyses and/or research issues of non-compliance as requested by management.

Other Job Requirements


PBM operations experience preferred.

  • Minimum of 5 years of Part D operations experience.
  • Knowledge of Pharmacy Benefit Manager (PBM) basic structure and processing systems.
  • Understanding of CMS policies related to Medicare Part D.
  • Ability to analyze Federal and State statutes and regulations for operational implementation.
  • Excellent interpersonal skills necessary to handle sensitive and confidential information, and to interact with a diverse patient population, providers and staff.
  • Strong sense of professionalism to allow for interactions with Sr. Management, and clients.
  • Strong PC and software application skills, including all aspects of Microsoft Office.
  • Requires a strong sense of time management and can interpret and help operationalize CMS regulation to remain compliant.
  • Experience with data entry.
  • Ability to work collaboratively with multiple teams
  • Excellent administrative/organizational skills; advanced analytical ability required in order to gather and interpret data, and resolve moderately complex problems.
  • Excellent leadership skills, including the ability to prioritize, problem-solve and multi-task in a fast-paced environment.
  • Requires reinforcing quality and customer service standards; analyzing and resolving quality and customer service problems; identifying trends, recommending process and procedural improvements.

General Job Information


Medicare Business Operations Specialist



Work Experience

Medicare Part D (MedD), PBM (Pharmacy Benefit Management)


A Combination of Education and Work Experience May Be Considered. (Required), Bachelors (Required)

License and Certifications - Required

License and Certifications - Preferred

Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.
Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their
position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Keywords: Magellan Health, West Valley City , Medicare Business Operations Specialist, Other , Herriman, Utah

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