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), serving as the primary point of accountability 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 all CMS Part D requirements under 42 CFR Part 423 as applicable to PACE. Oversees Part D reporting obligations, including annual attestations, DIR fee reconciliations, and TrOOP (True Out-of-Pocket) cost tracking.
Financial Management & Plan Performance: Develops, manages, and monitors 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 on behalf of Jordan Valley Senior Care.
Regulatory Compliance & CMS Oversight: Leads preparation for and management of CMS Program Integrity audits, CMS compliance program effectiveness reviews, and state Medicaid audits. Oversees PACE HPMS, CMS, and actuarial (Milliman and Mercer) 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. Establishes departmental goals, performance standards, and work plans aligned with organizational strategic objectives.
Qualifications
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.
One year of experience working with a frail or elderly population or appropriate training from the JVSC on working with a frail or elderly population upon hire.
BLS Certification required within 90 days of hire.