Senior Manager, Medicare Advantage Operations

As a key leader within Medicare Advantage Operations, the Senior Manager will be responsible for overseeing the strategic management and operational execution of Appeals and Grievances, Claims Processing, and Payment Integrity functions. In this role, you will ensure the efficient and compliant operation of all Medicare Advantage activities, aligning with CMS regulations and internal organizational standards. You will:

*Ensure timely, accurate, and compliant operations in accordance with CMS, DMHC, and internal standards.

*Collaborate with cross-functional teams to identify opportunities for operational improvements and process optimization.

*Lead new initiatives and projects aimed at improving efficiency and enhancing service delivery.

*Develop and implement best practices to improve team performance and regulatory compliance.

*Monitor key operational metrics, including inventory, aging, timeliness, and accuracy, to maintain high standards of performance.

We're seeking a self-directed individual with:

*A Bachelor's degree in business administration, healthcare administration or related field, preferred

*7 to 10 years of experience in a Medicare or Managed Care environment with responsibility for overseeing operations in appeals & grievances, claims processing, and/or payment integrity, highly desired

*5 or more years of management or progressive leadership experience in Medicare or Managed Care Operations, required

*Management or progressive leadership experience in Appeals and Grievances, Claims, and Payment Integrity, a plus

*5 or more years of experience with Medicare Advantage Health Plan operations, highly desired

*Knowledge of Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) jurisdictions

*Proven experience overseeing operations and vendor performance.

*Advanced proficiency in Microsoft Office Suite, particularly Excel (pivot tables, VLOOKUP), Word, and PowerPoint.

*Familiarity with SQL, data visualization tools, and healthcare-related software (e.g., claims processing systems, Tapestry, etc.), preferred

*Strong oral and written communication skills with the ability to articulate complex healthcare operations and technical processes to diverse audiences, required