Operations Planning Specialist (PDP Oversight & Monitoring)

Health Care Service Corporation•Nashville, TN

3d•$47,500 - $86,000•Remote

About The Position

The Operations Planning Specialist supports oversight and monitoring of individual Prescription Drug Plan (PDP) Enrollment and Premium Billing operations, including compliance with Centers for Medicare & Medicaid Services (CMS) requirements and support for mock audits and CMS plan audits. The role reviews operations for adherence to established processes, identifies improvement opportunities, and reports results through audit spreadsheets, dashboards, and scorecards. It also involves vendor oversight and collaboration, along with coordination across internal partners and lines of business to promote consistent processes. This is classified as a remote opportunity. Candidates must reside in and be authorized to work in a state where HCSC is approved to employ remote workers; applicants residing in restricted states, including Alaska, California, Hawaii, and New York, are not eligible. The position supports daily operational monitoring, CMS compliance reviews, audit activities, issue remediation, and readiness work related to enrollment and billing. Compensation is $47,500 to $86,000 annually, with exact compensation varying by skills, experience, and location. The role aligns with an annual incentive bonus plan, subject to its terms and conditions.

Requirements

Bachelor's degree or equivalent experience.
3–4 years of relevant Medicare (Part D and/or Part C) or other government program experience in eligibility, premium billing, or healthcare operations.
Proficiency with Microsoft Word, Excel, Outlook, and PowerPoint.
Self-motivation and ability to work in a fast-paced, heavily matrixed environment.
Ability to work independently and effectively as a team member.
Strong conceptual and analytical skills, including the ability to identify relationships between interfacing systems and processes, identify issues, and manage solutions through resolution.
Strong problem-solving skills and attention to detail.
Ability to analyze situations and work comfortably with ambiguity.
Capacity to learn process and product information quickly and efficiently.
Excellent organizational, written, and verbal communication skills.
Must reside in and be authorized to work in a state where HCSC is approved to employ remote workers; applicants residing in restricted states, including AK, CA, HI, and NY, are not eligible.

Nice To Haves

Knowledge of advanced Excel, report writing, and analysis activities.
Enrollment and eligibility experience and process improvement experience.
Medicare Advantage or Part D experience.

Responsibilities

Support daily oversight and monitoring of PDP Enrollment and Premium Billing operations with vendors, internal partners, and external partners, including the BPO vendor and Express Scripts.
Review and interpret new and existing CMS requirements to help ensure processes comply with CMS rules.
Monitor operational metrics, critical volumes, and daily inventory to proactively identify potential issues.
Review service-level agreements monthly and work with vendors and matrix partners to address issues affecting enrollment and billing operations.
Manage weekly monitoring activities, including pulling samples, tracking results and corrective-action evidence for CPE audits, and preparing results reports for leadership.
Conduct focused monitoring and audits following operational process changes or deployments.
Participate in and support internal, external, and CMS audits by quality-reviewing universes, samples, and supporting documentation.
Identify and communicate trends and issues found through monitoring, and work with business partners and vendors on remediation or process improvements.
Support additional duties and projects based on business needs, including AEP and 1/1 Readiness activities related to enrollment and billing.
Support annual review of vendor policies and procedures to ensure they are current with CMS guidance and company business policies.