Associate Director

SUMMARY

Responsible for the administration of $750 million in annual health care expenditures to 64,000 beneficiaries. Responsible for managing all in-house operational activities as well as those under contract with outside vendors. Coordinates and oversees the activities of all internal Operations and vendors’ staffs (over 250 people) to ensure that existing programs are operated in an efficient and effective manner and that new programs are implemented in a timely fashion. Serves as focal point for all Funds' activities relating to the health operational responsibilities of staff and outside vendors. Ensures that all claims processing, case management, call center, HCPP compliance audits, managed care, network development, pharmacy and operations activities are carried out in compliance with all applicable regulations, including administrative services agreements, the Funds’ administrative policies as well as the Funds’ Plans and Trusts. Ensures that all Funds’ programs are operational, and that budget guidelines are met for ongoing programs. Ensures that all new programs are administered in a similar manner.

PRIMARY DUTIES AND RESPONSIBILITIES include the following: other duties may be assigned.

Directs and oversees staff and all operational activities pertaining to the technical and analytical components of operations. Including Medicare compliance, HIPAA security, Medicare Audit, quality review, process consulting including improvement and creating efficiencies cross functionally, analytics and implementation of all newly acquired groups and plans. Cross functional accountability to the Deputy, Operations and Program Development. Establish a quality review unit that has oversight for quality assurance on defined output produced within the Operations and Program Development department and any tasks that have a financial impact to the Funds. Focus on pricing and fee schedule changes are executed in compliance with all applicable regulations, including administrative services agreements, the Funds’ administrative policies as well as the Funds’ Plans and Trusts. Develop and maintain an ongoing cross functional performance metrics, monthly quality checks, and unit scorecards. Accountable for cross functional collaboration for the Funds’ response to CMS compliance ensuring all requirements are deployed and meet regulations, monitor fraud waste and abuse. Oversee input and output relating to the audit of the annual cost report, and any applicable CMS Medicare Audits. Including staffing plans and resource allotment, training, discussions with the regulators, response to CMS and auditors including all reports and deliverables. Initiate quality improvement to correct any deficiencies discovered because of any internal findings or external audit(s) pertaining to claims processing, managed care programs, call center performance, network development activities for medical, vision, hearing benefits, and pharmacy program to ensure that all vendors and subcontractors perform the services as outlined in the current administrative services agreements and upholds the Funds expectation of excellence. Coordinates the Funds’ response to CMS relating to the audit of the annual cost report. Organizes a team that collects and reviews all medical records and any other information needed to support that the adjudication of claims meets CMS’ guidelines. Also initiates quality improvement to correct any deficiencies discovered because of the audit.

Monitors and reports to Trustees on all health and vendor programs as applicable and assigned by the director.

Monitors the Funds’ privacy policies and directs department personnel efforts who monitor, implement, and maintain compliance with HIPAA rules and regulations.

Coordinates all program changes with internal staff and vendors to ensure efficient and effective implementation of Medicare program changes, new cost management initiatives, or managed care systems/networks implementation.

Motivates his/hers direct reporting staff, ensuring they clearly understand the Funds’ health plans goals and mission. Monitors and reports on administrative costs relative to the claims processing activities and other program operation functions. Reviews Health Operations’ budget and monitors expenditures. Manages senior managers and program managers in the department and is responsible for the overall direction, coordination, and evaluation of this unit. Carries out managerial responsibilities in accordance with the Funds’ policies and applicable laws.

Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.

Responsible for adhering to all Funds’ policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information.

SUPERVISORY RESPONSIBILITIES

Manages all defined staff including managers and senior managers in Health Operations and is responsible for the overall direction, coordination, and evaluation of this unit. Carries out managerial responsibilities in accordance with the organization's policies and applicable laws.

INDUSTRY KNOWLEDGE

In-depth knowledge of health care insurance industry, including claims processing, cost management, Medicare, pharmacy benefit management programs and health policy. In-depth understanding of programs to manage contractor's systems planning and development strategies. An understanding or

QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

Bachelor's degree (B.A.) from four-year college or university; plus eight years related experience and/or training; or equivalent combination of education and experience.

LANGUAGE SKILLS

Ability to read, analyze, and interpret complex material (legal documents, government regulations, etc.). Ability to represent the Funds in responding to inquiries or complaints from beneficiaries, regulatory agencies, or members of Congress, or of the business community. Ability to write with precise language to communicate complex information (detailed business reports, policy statements, etc.) that conforms to prescribed style and format. Ability to effectively present information to internal staff, top management including the Executive Director and Trustees, outside contractors such as consultants, physicians and Third-Party Administrator, and beneficiaries.

MATHEMATICAL SKILLS

Ability to apply advanced mathematical, financial or statistical concepts to analyze complex information such as designing or developing statistical or financial models or reports.

REASONING ABILITY

Ability to define problems, establishes facts, provide creative solutions and support insights into highly complex problems.

CERTIFICATES, LICENSES, REGISTRATIONS

None required for this position.

OTHER SKILLS AND ABILITIES

Requires computer skills at an intermediate level, such as generating word processing letters/reports, intermediate spreadsheet usage, and/or operating printers and other peripheral devices.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Occasionally requires working overtime or hours significantly beyond the normal workday/work week, traveling during and outside of business hours and being on call more than regular number of business hours. Frequently requires working under tight time constraints. Constantly requires working in an area in which the work product is subject to very precise measures of quantity and quality.

COMPLETE BACKGROUND CHECK REQUIRED.