Medicare Operations Senior Program Manager

Blue Cross Blue Shield Association•Baltimore, IN

1d•$105,400 - $152,800•Remote

About The Position

This role will be responsible for operations management of the Federal Employee Program (FEP) Medicare Advantage (MA) EGWP line of business. Responsible for overseeing day-to-day operational work streams that support Medicare products and services to ensure operational/regulatory compliance consistent with FEP, Office of Personnel Management (OPM), and Centers for Medicare and Medicaid Services (CMS), and EGWP policies and procedures. Manage operational efficiencies/continuous improvement initiatives and support operational implementation of cross-functional initiatives to enhance member and provider experiences. This position partners closely with FEPOC MA Operations, Compliance, Product, Clinical, Network, and Inter Plan & Products (IPP) teams to ensure product builds are compliant, timely, and operationally sound. Position will serve as the primary interface with operations and implementation partners throughout the product cycle and will play a critical role in driving the success of the company's product portfolio by delivering products that meet business objectives. Manages business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders. Ensures adherence to FEP program and ITS processes/procedures and applies deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance and audit readiness. Manages pre/post-launch operational monitoring, identifies execution gaps, and drives in-year corrections to maintain product integrity and compliance. Relationship management skills to build and maintain a positive, collaborative working relationship across various internal and external functional areas/stakeholders. Establish cohesive relationships and influence decisions without having a direct functional reporting structure. Build trust, exhibit sense of urgency, drive consensus in resolving conflicts and decision making. Resolve or escalate issues, propose alternatives and set or manage expectations in a timely fashion. Manages product implementation and operational readiness as directed by product development team in ensuring benefit builds at the operations and implementation partner level align precisely with approved CMS-compliant specifications. Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives. Supports Product Development team with strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking. Manages vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS. Manages collating MA product operational performance reporting including all applicable KPIs, SLAs, regulatory, and operational reporting metrics and appropriately distributes to BCBSA leadership. Serves as a liaison and communicator to FEPOC Operations team, presenting recommendations to leadership and mentoring operational staff.

Requirements

BS in Healthcare, Business Administration, Public Health, or related field; or equivalent experience
8+ Years experience in Medicare/Medicare Advantage Operations, healthcare operations, and health insurance or managed care.
Deep knowledge of Medicare Advantage, Part D, and CMS regulations.
Experience leading/supporting large, cross functional programs/projects, including working with TPAs/BPOs.
Experience working with core processing platforms like – Facets, HealthEdge, QNXT etc.
Strong analytical skills with ability to interpret utilization data, competitive benchmarking, and quality/Stars metrics to drive benefit enhancement decisions.
Excellent written, oral communication, and presentation skills; proven ability to develop and deliver executive-level materials and represent product initiatives to senior stakeholders.
Proficiency in Microsoft Office (Word, Excel, PowerPoint); familiarity with project management tools and data visualization platforms.
Strong stakeholder management and relationship-building skills with the ability to influence without authority across Legal, Compliance, Actuarial, Clinical, and Operations functions.

Nice To Haves

Lean Six Sigma and industry benchmarking for process optimization.

Responsibilities

Oversee day-to-day operational work streams that support Medicare products and services to ensure operational/regulatory compliance consistent with FEP, OPM, and CMS policies and procedures.
Manage operational efficiencies and continuous improvement initiatives.
Support operational implementation of cross-functional initiatives to enhance member and provider experiences.
Partner closely with FEPOC MA Operations, Compliance, Product, Clinical, Network, and Inter Plan & Products (IPP) teams to ensure product builds are compliant, timely, and operationally sound.
Serve as the primary interface with operations and implementation partners throughout the product cycle.
Manage business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders.
Ensure adherence to FEP program and ITS processes/procedures and apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance and audit readiness.
Manage pre/post-launch operational monitoring, identify execution gaps, and drive in-year corrections to maintain product integrity and compliance.
Build and maintain positive, collaborative working relationships across various internal and external functional areas/stakeholders.
Influence decisions without having a direct functional reporting structure.
Build trust, exhibit a sense of urgency, drive consensus in resolving conflicts and decision making.
Resolve or escalate issues, propose alternatives, and set or manage expectations in a timely fashion.
Manage product implementation and operational readiness as directed by the product development team.
Ensure benefit builds at the operations and implementation partner level align precisely with approved CMS-compliant specifications.
Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives.
Support the Product Development team with 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.
Manage collating MA product operational performance reporting including all applicable KPIs, SLAs, regulatory, and operational reporting metrics and appropriately distribute to BCBSA leadership.
Serve as a liaison and communicator to the FEPOC Operations team.
Present recommendations to leadership and mentor operational staff.