Manager, Government Programs (EGWP) at Judi Health · Charlotte

Location: Hybrid (Local to NYC, Denver, CO or Charlotte, NC)

Position Summary:

The Government Programs EGWP Manager is responsible for the implementation, operational oversight and change management of regulatory requirements for the Health Plan EGWP line of business. The role will be responsible for daily management and ongoing oversight of highly vulnerable activities with the Medicare part D Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). This role will perform the day to day functional activities to ensure compliance with the Centers of Medicare and Medicaid (CMS) regulations while meeting employer, member and Health Plan financial objectives.

Position Responsibilities:

• Manage EGWP program setup, implementation and go-live readiness across assigned internal functions and delegate oversight, which includes claims processing and associated functions, clinical programs and activities oversight, STARs and Audits.
• Provide day to day management to operations analyst EGWP
• Oversee and monitor the financial performance, operational KPIs and CMS compliance metrics for PBM claims, formulary, coverage determinations, appeals and grievances (CDAG)
• Manage issue resolution and corrective action completion with related, first tier and downstream entities (FDRs).
• Perform outreach as necessary on plan to plan activities, FIR transaction corrections and other financial transactions that may require Health Plan interventions.
• Lead regulatory reporting to ensure timely and accurate reporting from both internal and external resources as required by the Health plan, the State and CMS.
• Collaborate cross functionally across the Judi Health organization on employer group issues, communications and required oversight of Health Plan functions performed by employer groups and/or delegates.
• Support internal and external audits by federal and state agencies, including audit preparation, documentation, issue response and remediation tracking.
• Develop compliant documentation for operational areas to include policies, procedures, workflows and other work instructions.
• Support Health Plan team with member communications, enrollment and member services oversight, and other functions as needed.

Required Qualifications:

• Minimum of HS diploma/GED or equivalent experience
• 5+ years of Medicare Part D and/or EGWP experience
• Deep knowledge of Medicare Part D claim processing requirements, CDAG oversight and monitoring, and Health Plan Part D reporting.
• Experience working in a delegated and highly matrixed organization.
• Strong operational acumen

Preferred Qualifications

• Health Plan Medicare Part D and/or EGWPs
• Experience working within CMS systems, including but not limited to HPMS and MARx.
• Experience with CMS, CMS Contractor and State Audits
• Strong analytical acumen