Health Plan Manager, Jordan Valley Senior Care (JVSC) PACE

About the role

The Health Plan Manager oversees all health plan operations within Jordan Valley Senior Care (PACE). This position is responsible for Medicare Part D oversight, financial performance, claims adjudication and processing, and regulatory contracting compliance.

Responsibilities

• Medicare Part D Pharmacy Benefit Oversight: Collaborates with the Clinical Pharmacist to ensure compliance with CMS Part D requirements, monitors and oversees Part D reporting, and manages COB for participants with third-party coverage.

• Financial Management & Plan Performance: Develops and manages the health plan operating budget, analyzes financial performance, and coordinates with the finance department on IBNR reserve calculations and encounter data reconciliation.

• Claims Administration & Adjudication: Oversees claims processing operations, establishes and maintains claims processing standards, and oversees encounter data submission to CMS and the state Medicaid agency.

• Contracting & Network Management: Negotiates, executes, and manages contracts with specialty providers, ancillary service vendors, hospitals, and other healthcare entities.

• Regulatory Compliance & CMS Oversight: Leads preparation for and management of CMS Program Integrity audits, maintains a robust compliance monitoring program, and oversees PACE HPMS, CMS, and actuarial reporting obligations.

• Quality Improvement & Reporting: Oversees QI activities related to health plan operations and collaborates with the IDT and clinical leadership to review per-member-per-month (PMPM) claims trends.

• Leadership & Staff Management: Recruits, hires, develops, and evaluates health plan operations staff, and fosters a culture of compliance, accountability, and continuous improvement.

Requirements

• Bachelor’s degree in health administration, business administration, public health, or nursing preferred, or equivalent work experience required

• Minimum of 1-2 years of progressive experience in health plan operations

• Two years in a supervisory or management capacity

• Demonstrated experience in health plan contracting, claims operations, or regulatory compliance

• Two years work experience in accounting/finance

• Either one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the JVSC on working with a frail or elderly population upon hire

• BLS Certification required within 90 days of hire