Director, Medicare D Membership Operations - Pharmacy Benefits Management

Insurance

Director, Medicare D Membership Operations
Pharmacy Benefits Management

St. Paul, MN

Prime Therapeutics LLC is a pharmacy benefits solutions company dedicated to providing innovative, clinically-based, cost-effective pharmacy solutions for clients and members.

We are seeking an insurance professional with a solid business background to be responsible for the overall development, improvement, and ongoing management of eligibility administration and processing for Medicare D business and clients. Responsibilities include the reprocessing of claims based on retro-eligibility changes and the reconciliation of eligibility data between Prime and its vendors. This position is also responsible for the administration of online and paper submitted coordination or benefits.

Specific accountabilities:

Manage the eligibility process department in order to coordinate workload, ensure quality, establish procedures (i.e. SOPs) and maintain existing procedures, exceed performance guarantees, and manage the costs of the services being provided.
Provide leadership for the eligibility and COB process teams in the areas of problem resolution, team development, and personal development. Serve as the department resource for escalated client issues. Remain knowledgeable of CMS regulations pertaining to Medicare D eligibility, claims processing, and COB.
Serve as a department representative to the company and external entities: participate in cross-company initiatives, work with clients during the implementation process and ongoing to update processes and to resolve any issues and work with external vendors to ensure a consistent product.
Establish and maintain relationships with client Eligibility and Claims Processing functional management related to Medicare Part D. Communicate regularly and establish and manage a level of continuous improvement internally and between Prime and clients.
Manage eligibility processing by establishing thresholds and analyzing trends to offer the client solutions to more effectively manage eligibility processing. Understand current tools and reports available (error reports, threshold edits, and others to be developed as necessary) to assist in identifying and implementing recommendations.
Manage vendor relationships related to eligibility administration and coordination of benefits. Current responsibilities include eligibility functions related to the issuance of ID cards, Medicare Part D enrollment (including enrollment reconciliation, retro-eligibility adds, group adds, low income subsidity changes, effective date changes, etc.)
Direct the resolution of escalated client issues related to eligibility and claims processing for Medicare D clients and products (including the management of Prime?s internal escalation database). Facilitate cross-functional initiatives to resolve situations. Participate in sales and implementation activities to proactively recommend solutions.
Direct the collaboration with other departments on department and company enhancements.
Manage and report results as agreed to in performance guarantees.
Serve as a company representative during audits for eligibility and COB related topics. Work with external auditing company to determine the appropriate level of documentation to provide. Work with the external auditors during the on-site visit and be a resource to auditors during their off-site review.
Oversee coordination of benefits administration and claims reprocessing based on retro-eligibility changes. Provide strategic direction to the team handling escalated inquiries related to Medicare D and commercial payment order and adjustments. Provide metrics reporting involving daily activities.
Oversee reconciliation team to ensure regular and ad hoc procedures and activities are in place to remain in synch with enrollment and eligibility vendors. Provide metrics reporting involving daily activities.

Qualifications:

Bachelor?s degree or equivalent work experience, with 5 ? 7 years health care and/or eligibility process experience.
5 ? 10 years of management experience.
Medicare and/or government program experience preferred
Strong interpersonal communication skills, including team leadership, conflict resolution and listening.
Ability to manage multiple, complex projects simultaneously without compromising quality.

At Prime, you will enjoy a supportive environment and plenty of advancement opportunity within a fast-growing business. You will also be rewarded with a competitive salary and benefits package.

For confidential consideration, please apply online at:
www.primetherapeutics.com/aboutrecruitment.htm

Prime Therapeutics LLC
1305 Corporate Center Drive
St. Paul, MN 55121

Equal Opportunity Employer