Medicare Operations Director

Blue Cross Blue Shield Association•Washington, DC

1d•$141,000 - $180,000•Hybrid

About The Position

Provide end-to-end operational leadership for the Medicare Advantage (MA) program, overseeing day-to-day operations, compliance, vendor management, and strategic execution across the member lifecycle. Drive operational excellence through metrics, governance, regulatory adherence, and continuous improvement while partnering closely with FEP leadership, Plans, IT, vendors, and CMS.implementation support to long-term operational stewardship. Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development. Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls. Lead business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders. Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement. Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking. Manage vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS. Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives. Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff.

Requirements

Minimum 5-7 years of Medicare Advantage operational experience
Experience with health plan administration systems and platforms
Comprehensive understanding of Medicare Advantage regulations, CMS requirements, and compliance standards (including Star Ratings, RADV, risk adjustment)
Strong vendor management and contract oversight capabilities
Excellent business analysis and requirements documentation skills
Strategic thinking with ability to transition from tactical execution to long-term planning
Proficiency in process improvement methodologies (Lean, Six Sigma)
Strong project coordination and organizational skills with ability to manage ambiguity
Exceptional written and verbal communication abilities
Proven ability to influence without authority and build consensus
Change management and organizational development capabilities
Ability to manage multiple priorities in a fast-paced, dynamic environment
Proven track record writing business requirements and supporting system implementations
Experience working in health plan operations or similar healthcare environment
Familiarity with Agile/Waterfall project methodologies
Proficiency in Microsoft Office Suite, particularly Excel and Visio

Nice To Haves

Experience with Federal Employee Program or federal health benefits programs, preferred
Background in both operational and technical aspects of MA plan administration preferred
Experience working with FACETS claims processing system to manage healthcare claims adjudication, benefits configuration, and member eligibility, ensuring accurate and timely claims processing and resolution.
Experience leveraging AI technologies (machine learning, natural language processing, automation tools) to streamline operational processes and enhance customer experience, resulting in measurable improvements in efficiency, cost reduction, and customer satisfaction.
Experience with requirements management tools preferred
Demonstrated experience managing vendor relationships, preferably with system integrators
Previous experience in a matrixed organizational structure preferred
PMP, PGMP, CBAP, or similar professional certification preferred
Knowledge of healthcare data standards (HIPAA, X12, HL7) preferred

Responsibilities

Provide end-to-end operational leadership for the Medicare Advantage (MA) program
Oversee day-to-day operations, compliance, vendor management, and strategic execution across the member lifecycle
Drive operational excellence through metrics, governance, regulatory adherence, and continuous improvement
Partner closely with FEP leadership, Plans, IT, vendors, and CMS
Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development
Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls
Lead business requirements, system implementations, UAT, and change management
Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement
Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking
Manage vendor relationships, contracts, and RFPs
Represent MA operations in governance forums and with CMS
Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives
Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff