Director, PBM Technical Operations

Navitus Health Solutions, LLC

2d•Remote

About The Position

Navitus Health Solutions is seeking a Director, Technical Operations with no less than 5 years of experience at a PBM, health plan, or managed care environment to join our team! This is not a call center or general operations leadership roles. The Director, Technical Operations (DTO) is responsible for providing regulatory interpretation, operational expertise and oversight of technical programs for Government Programs which include enrollment/eligibility, regulatory encounter submission and reconciliation, claims adjudication accuracy, EOB Administration, recoveries processes, EGWP enrollment, coordination of benefits, reprocessing/refund/recoveries solution deliverables, M3P, vendor contract management and RDS Administration. The Director will recommend, develop, implement, monitor and evaluate department goals, objectives, processes, and policies and procedures within the scope of the department’s responsibilities. The DTO is responsible for the development, implementation and ongoing oversight of the technical operations and activities needed to support Government Programs. This individual will ensure that policies, procedures, and CMS and state program requirements are implemented to achieve effective, efficient, auditable and compliant Medicare, Medicaid and Exchange Claims Adjudication.

Requirements

Bachelor’s Degree required.
5 years’ experience in PBM, health plan, or managed care environment.
Knowledge and experience in project management, claims adjudication, analytical tools and analysis, and technology solutions.
Requires proven track record of process improvement, regulatory compliance, monitoring and metrics, and leading projects and teams.
Participate in, adhere to, and support compliance program objectives
The ability to consistently interact cooperatively and respectfully with other employees

Responsibilities

Supports annual department budget and staffing plans in support of Navitus’s strategic and business initiatives.
Monitors program regulations, guidance, and systems to determine needs and gaps that impact compliance and program operations. Provides direction and oversight for the development, modification and improvement of business processes and policies.
Oversees the accurate and timely administration, coordination, reconciliation and reporting of eligibility changes including CMS enrollment submissions for EGWP offering; retroactive Medicare D low-income subsidy eligibility changes; retroactive eligibility changes and impact assessments for Medicaid and Exchange, and changes in the primary and supplemental other insurance file and COB changes.
Oversees the processing of all CMS and state encounter data submissions and reconciliations. Ensures PDE, ED, and Exchange encounter submissions and manual and electronic claims adjustments to correct PDE/ED errors and recoveries are handled appropriately and timely. Oversees outcomes adherence to contractual and performance guarantee requirements and creates the vision for and oversees all related projects and process improvements.
Oversees and ensure compliance with the Medicare, Medicaid and Exchange claims adjudication and COB regulatory requirements.
Oversees and ensure compliance with the Medicare EOB regulatory requirements and administration as well as Medicare M3P administration and vendor management.
Oversees and ensure compliance with reprocessing regulatory requirements and timelines.
Ensures successful internal and external audits by working with claims adjudication and recoveries teams to maintain compliance with regulatory requirements and requirements for operational and financial controls.
Implements new Medicare D, Medicaid and Exchange requirements impacting claims adjudications, RDS, EGWP enrollment, EOB administration, encounter data administration, Medicare Plan Finder, and retro-eligibility requirements.
Other duties as assigned