AVP Enrollment & Premium Reconciliation - Medicare

JOB SUMMARY:
The Associate Vice President, Enrollment and Premium Integrity, is responsible for development, implementation and ongoing oversight of the enrollment and premium operations needed to support Medicare Advantage plans and other products implemented by AMERIGROUP’s Senior Services Organization (SSO). This individual provides the skills, expertise and leadership needed to ensure the success and effectiveness of the SSO’s Enrollment and Premium Reconciliation operations. Working with the Chief Operating Officer of the SSO, this individual will ensure that relevant policies and procedures, state and federal Medicare program requirements are implemented to achieve effective, efficient, auditable and compliant operations.

PRIMARY RESPONSIBILITIES:
•Ensure success of SSO enrollment and premium operations through management of designated teams within each operational area. Work with functional managers to negotiate resources, process improvement and appropriate training.
•Develop, implement and oversee operational processes to ensure maximization of Medicare Advantage and Part D premium revenue methodology, including effective member/premium reconciliation, accurate and timely transaction processing.
•Develop, implement and oversee corresponding processes for state payments of Medicare cost-sharing and state-funded benefits.
•Ensure accurate and timely administration, coordination, reporting and reconciliation of Medicare enrollment, health services encounter data, risk adjustment factors, special statuses and other elements affecting member premiums.
•Work with the Pharmacy Division and pharmacy benefits management vendor to ensure accurate and timely administration, coordination, reporting and reconciliation of Part D enrollment, pharmacy encounter data, reinsurance and low income subsidy payments; and other health insurance information.
•Develop and monitor management reports that measure expected service levels, data and processing quality, and production volumes of all operational components.
•Serve as business owner for enrollment and premium processes during implementation of new Medicare expansion areas.
•Increase the organization’s knowledge and understanding of Medicare program requirements through presentations and training materials related to enrollment and premium reconciliation.
•Contribute to the growth of the Medicare line of business by developing, modifying and improving business processes and target environment as needed.
•Implement effective and appropriate program communications plans. Monitor relevant state and CMS systems, guidance and notices. Lead initiatives to communicate changes and modify processes and documentation as needed
•Ensure successful internal and external audits by working with operational teams to maintain compliance with regulatory requirements and requirements for financial and operational controls. Ensure adherence to appropriate processes, methodologies, policies and procedures.
•Work with the COO and other members of the SSO management team to identify and resolve any issues that may hinder program success.
•Other Duties as Assigned
REQUIREMENTS
EDUCATION AND EXPERIENCE:
Education
Required: Bachelor’s required (major in Business, Health Care Management or equivalent preferred)

Preferred: Master’s preferred.
Years and Type of Experience
Required:
•Minimum of ten years experience in Health Plan industry required.
•Minimum seven years progressively responsible experience managing and supervising health plan operational processes required, including enrollment and premium reconciliation.
Preferred:
Specific Technical Skills
Required:
Preferred:
Certifications or Licensure
Required:
Preferred:
Other
Required:
•Exceptional leadership capabilities with a strong work ethic, and the ability to keep pace with AMERIGROUP’s fast-paced environment.
•In-depth knowledge of Medicare Advantage program enrollment, premium, and payment regulations, policies and requirements.
•Excellent analytical and process improvement skills
•A dedicated team builder and player who is capable of operating effectively with a minimum of direction, and who enjoys interaction with all levels within an organization.
•A resourceful self-starter with a high level of intelligence and energy.
•Effective presenter and problem solver with strong negotiation and management skills.
Preferred:

SCOPE INFORMATION

ItemMeasure
•# Direct Reports
•# Indirect Reports
•Budgetary $ Responsibility
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PHYSICAL REQUIREMENTS
•Able to conduct and facilitate meetings
•Able to operate a computer.
•Able to travel upon request.

Please apply online at: www.amerigroupcorp.com