The Medicare Program Director, reporting to the Chief Strategy and Governments Affairs Officer,
is responsible for plan management and informing operations of Partnership’s Medicare dual
special needs plan (D-SNP). This position provides direction to health plan departments to ensure
compliance with regulatory agencies such as the Centers for Medicare and Medicaid (CMS) and
maintains working knowledge of health plan obligations of other regulators including Department
of Health Care Services (DHCS) and Department of Managed Health Care (DMHC). Responsible
for leading strategic initiatives and projects, ensures deliverables are on time and in alignment with
strategic initiatives, and in doing so, supports continuity of product lines.

▪ This role is accountable for establishing and leading a multi-year, growth strategy for
Medicare line of business. Solicits input on market needs from stakeholders across the
organization, provider network, community partners, and members.
▪ Coordinates and collaborates with all business operations associated with the Medicare
lines of business and health plan operations, including coordination with and oversight
of delegated networks, contracted providers and contracted vendors.
▪ Proactively works with key internal and external stakeholders to implement policies,
procedures and/or initiatives that fulfill the organization’s goals, strategic priorities and
mission.
▪ Manages the development and approval of Medicare policies. Responsible for the
application of Medicare policies and providing input on other departments’ related
policies and procedures.
▪ Partners with staff from across the organization to research specific issues as necessary to
develop and analyze solutions and make policy or programmatic recommendations to address
operational issues.
▪ Accountable for understanding current and prospective State policies related to Duals, and the
corresponding implications for product design, operating model alignment, regulatory
compliance, and financial and operational coordination of benefits and payment policy
execution.
▪ Partners with the Finance Department and ensuring an optimal CMS bid strategy while
accounting for all State regulatory, policy, and operational parameters, inclusive of an
intimate understanding of how CMS payment models and risk adjustment program
parameters impact our strategic, financial, and operational approach.
▪ Partners with the Pharmacy Department to align formulary strategies and operational
parameters with optimal product design and performance.

▪ Analyzes and recommends specific product strategies for Dually Eligible beneficiaries
based on population and segmentation analysis to include D-SNP where appropriate for
the market, and that align around broader strategic, growth, quality, and margin objectives.
Develops and monitors strategies and tactics for business development, new member
enrollment and member retention in Medicare program.
▪ Communicates the plan’s operational issues, ensures adherence to work plans, identifies
problem areas and develops solutions to issues or problems specific to the Medicare program.
▪ Through competitive intelligence, market research, and data driven analytics,
identifies opportunities for innovation in product design, network configuration,
strategic partnerships, service improvements, and affordability opportunities.
▪ Develops the comprehensive member journey starting with enrollment and onboarding,
and including assisting with market-based engagement strategies, care management
assignment and coordination, population health management programs, and delivery
system design and navigation.
▪ Stays abreast of health care policies, regulations and changes as it relates to those issued
by CMS, DHCS, DMHC, NCQA and/or other associated agencies.
▪ Utilizes data to analyze and support program outcomes and ongoing evaluation of the
organization’s Medicare program.
▪ Works with Regulatory Affairs and Compliance team (RAC) to ensure Partnership’s
Medicare compliance with regulators, contractual requirements and/or accreditation
standards; participates in health plan audits, as needed.
▪ Prepares narrative and statistical reports and makes presentation(s) on program activities
to necessary committees, community partners and/or executive leadership.
▪ Participates in vendor management as required by reviewing vendor performance levels;
ensuring service level agreements are met; managing vendor invoices; and partnering
with Procurement, Legal, and/or leadership teams to develop service level and/or scope
of work agreements as appropriate.
▪ Partners with members of the Executive Team to identify short and long-term department
goals and to provide strategic direction on initiatives.
▪ Assigns workload and monitors staff performance. Evaluates unit priorities and makes
changes as necessary.
▪ Provides on-going coaching, mentoring, and development of employees, fostering an
atmosphere of teamwork. Establish individual team member goals and assist in the
achievement of those goals.
▪ Other duties as assigned.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$180,252.50 - $243,340.87

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.