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Manager, Medicare Operations - Billing and Enrollment

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POST DATE 9/16/2016
END DATE 12/20/2016

Horizon Blue Cross Blue Shield of New Jersey Newark, NJ

Newark, NJ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Job Summary:

Responsible for the operational oversight of Medicare Operations - Billing and Enrollment in Government Programs to ensure the performance goals are achieved in a highly regulated environment. Ensure employees achieve prescribed service, timeliness and production standards as defined by internal/external customers, members, regulators and/or the marketplace.


* Responsible for the accuracy and timely completion of all reconciliation, reporting procedures and coordinating review of files to correct errors for resubmission to ensure fulfillment of contractual obligations to the Centers for Medicare and Medicaid Services (CMS) and all regulatory agencies.

* Oversightof Medicare Advantage and PDP enrollments, plan changes, disenrollments, denials, cancellations, and incomplete requests. Responsible for directing the research and disposition retroactive enrollment and enrollment cases that derive from Reconciliation reporting, Account Management, CTM, Grievance, Pharmacy (PDE), Medicare Operations, Member Services, and Premium Billing.

* Responsible for creating and monitoring operational process controls and initiating all resulting corrective actions necessary to ensure staff follows all operations department procedures.

* Identify and manage operational process and quality improvements to optimize performance and administrative cost. Acts as a staff resource for quality improvement and maintains quality indicators and data analysis and reports results to committees.

* Accountable for maintaining effective internal controls over the processes and transactions under areas of responsibility including the completeness and accuracy of financial information and transactions; eligibility data processing;compliance with applicable laws and regulations, reconciliation and reporting; billing and enrollment; and the effectiveness and efficiency of operations.

* Lead or participate in both internal/external workgroups/committees, maintain internal/external business partnerships and represent department/enterprise where appropriate.

* Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.

* The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.


* Knowledge of Medicare Managed Care Program, interpretation of CMS guidelines, and writing correspondence Operational Policies and Procedures.

* Knowledge and understanding of CMS Enrollment Guidance.

* Knowledgeable in basic and analytical mathematics.

* Proficient use Microsoft Office applications, e.g. Excel, Word

* Requires experience with process improvement and process controls set in place.

* Requires experience working with metrics or key performance.

* Requires experience working with IT in terms of participation in defining system requirements.

Skills and Abilities:

* Communications, Interpersonal, Negotiation, Leadership & Coaching, Analytical, Problem Solving.


* Requires a Bachelor s degree form an accredited college or university in a related discipline.


* Requires five (5) years Medicare/Medicaid operations experience including Medicare enrollment processing and/or Membership Reconciliation.

* Requires a minimum of 5 years management experience.

* Requires a minimum of 5 years of experience in a regulated industry working with audits.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.



Job Level

--Horizon NJ Health

Job Type
Full Time

Newark, NJ