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Director, Medicare Advantage Operations

Company: CareFirst BlueCross BlueShield
Location: Owings Mills
Posted on: October 18, 2020

Job Description:

Resp & Qualifications

Responsibilities & Qualifications

PURPOSE: Directs Medicare Advantage Claims or Service or Enrollment and Billing or non-clinical appeals and grievance departments to ensure that operations or delegated functions run with optimum efficiency and compliance with CMS requirements to achieve all internal and external corporate goals and objectives. Responsible for the delivery of the highest levels of member, account and provider satisfaction and/or that claims and inquiries are handled in a consistent, timely, cost effective and high-quality manner, while providing support to all internal areas as needed. Ensures attainment of goals by developing, approving and implementing operational strategies, plans and objectives, monitoring and ensuring the efficiency and effectiveness of the operation, evaluating work flows, procedures, policies and staffing needs, and always adhering to external, corporate and customer/provider standards for quality, timeliness and accuracy. Responsible for the development and implementation of strategies and tactics to ensure continued improvement in the synchronization of systems, people and processes.


Under the general supervision of the Vice President, the Director s accountabilities include, but are not limited to, the following:

* Directs the activities of the Claims or Service or Enrollment and Billing or Non-clinical Appeal and Grievance departments or outsourced vendor by reviewing and analyzing claims inventories, timeliness, accuracy, compliance, member experience, productivity, cost, appeals, and complaint reports, or equivalent customer service data, to strategically determine the allocation of staff, training needs, and improve current processes to consistently exceed all performance expectations.
* Responsible for identifying and resolving corporate issues involving respective departments.

* Responsible for planning and monitoring departmental activities and needs, collection and analysis of performance data, and performance management of Managers and other staff reporting to this position. Responsible for meeting staffing needs, vendor oversight, associate development, and performance assessment of all direct and indirect reports.

* Participates in Operations projects and meetings in order to achieve and maintain optimum efficiency, compliance and satisfaction standards.


Direct reports include, but are not limited to, Operations Managers and non-management staff such as Administrative Assistants, Project Managers, and Operations Trainers. Provides oversight of up to approximately 5 - 100 indirect reports and 2-3 direct reports.


This position impacts:

* the size and satisfaction of provider networks
* member and account satisfaction levels and retention
* all areas that interact with Members and Providers throughout the corporation
* directly accountable for meeting all internal and external quality and productivity goals, which may include, but are not limited to the following sample key section level goals:

** CSR Availability
** Inquiry Accuracy
** Inquiry Timeliness
** Attendance
** MTM
** Account Performance Standards
** Claims Dollar Accuracy



* Bachelor s Degree in Business Administration, Healthcare Administration or related discipline or equivalent professional experience.
* 8-10 years of progressively responsible managerial functions in a customer service, claims, appeal and grievance and/or enrollment and billing related discipline, with at least 4 of those years in Medicare Advantage operations. Health Insurance and Call Center Experience, including knowledge of state-of-the-art technology.


The individual must have extremely strong analytical and problem-solving skills, and the ability to develop and implement policies and programs that will advance corporate and operational goals and objectives. Excellent planning, problem solving, negotiation, presentation, written and oral communication skills are required. Excellent interpersonal skills, the ability to effectively manage a staff through leadership and the promotion of teamwork is essential. The incumbent must possess excellent interpersonal skills and highly developed written and oral communication skills to effectively convey complex and detailed concepts to a diverse audience. The incumbent must possess extremely well developed organizational and prioritization skills.


Master s degree preferred



Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: (

Closing Date

Please apply before: 10/19/2020

Federal Disc/Physical Demand

Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.


The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

Keywords: CareFirst BlueCross BlueShield, Baltimore , Director, Medicare Advantage Operations, Executive , Owings Mills, Maryland

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