Medicare Operations Jobs (NOW HIRING)

This position is not available for visa sponsorship.
Applicants must be located in Southern California.
Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
Who Are We?
Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.
Why Join Us?
We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
Job Summary
The Medicare Operations Configuration Analyst oversees the system development and configuration activities and file exchange processes of the Enrollment department while ensuring its processes operate smoothly. The Medicare Operations Configuration Analyst also works with other internal stakeholders, customers, vendors, and with federal and State agencies to resolve eligibility issues in order for the plan to continue receiving payment for medical services provided.
Functions & Job Responsibilities
• Assists in the configuration of the Eligibility Manager and EzCap Eligibility Modules to facilitate processing and storage of enrollment data.
• Analyze, review, monitor, and control the Enrollment file reconciliation operation with efficiency and effectiveness.
• Assists with the design/revision and implementation of internal departmental systems and procedures.
• Coordinate file production for the submission and monitoring of daily, weekly and monthly inventory reports to determine departmental efficiency and maintain the integrity of the enrollment file.
• Assists the Enrollment team to ensure timely and accurate completion of all required eligibility documents, accurate recording of assessments, and guaranteeing productivity standards.
• Coordinate interdepartmental projects with other areas of the organization; including Retention, IT, Marketing departments, Compliance, and Provider Relations.
• Work closely with the Local department of Social Service, HRA, and Maximus to ensure timely submissions and resolution of eligibility issues, as well as establishing departmental goals and ensuring quality goals are met.
• Analyze workflows, identify deficiencies, and develop more efficient processes.
• Prepare enrollment analysis and enrollment reports for the Manager of Enrollment.
• Oversee surplus billing and work closely with the Finance department in the reconciliation of capitation payments.
• Direct the implementation of Medicare regulations and related products.
• Serve as a subject matter expert and coordinate departmental procedures.
• Ensure compliance with company and statutory policies.
• Develop departmental policy and procedural documentation.
• Ensure the required member mailings are sent in a timely fashion.
• Run ongoing reports for various Medicare Operations Key Performance Indicators
• Develop summaries from reports for management to develop action plans and interventions.
• Assist with creating benchmarks for various Medicare Operations teams to ensure teams are operating efficiently.
• Assist with creating data visualization models to help convey complex data sets in a simplified and easy to digest manner.
• Develop AD-HOC reports as the necessity presents itself.
• Other duties as assigned
Qualifications
Education and Experience:
• Three (3) years' healthcare industry experience, preferably with Medicare Advantage plan or Managed Care
• Two (2) to four (4) years progressive work experience in business or health operations preferred.
Skills:
• Deep understanding of government programs including Medicare Advantage
• Expert knowledge of Medicare reimbursement methodologies.
• Strong knowledge of Medicare Sound judgment, tact, and discretion, with the ability to work with Company employees at all level
• Strong interpersonal skills and the ability to establish a rapport with all levels of an organization.
• Strong customer service skills.
• Exceptional written and verbal communication skills.
• Ability to convey complex or technical information in a manner that is easy to understand.
• Intermediate computer knowledge, Excel, Word, PowerPoint, prominence, ACD system, Adobe Acrobat.
• Intermediate SQL skills for data querying and analysis
• Experience with data visualization tools such as Tableau, Quicksight or Power BI
Physical & Working Environment.
Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
This is an exciting opportunity for a dedicated professional to contribute to the success of our Medicare Operations and make a positive impact on the delivery of healthcare services to our members. If you are passionate about healthcare administration and have a keen eye for data and detail, we encourage you to apply for this position.