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Navitus Health Solutions · 23 hours ago

Director, PBM Technical Operations

United States

Full-time

Remote

Lead/Staff, Director/Executive

$121K/yr - $151K/yr

5+ years exp

Navitus Health Solutions is committed to making medications more affordable and is seeking a Director of Technical Operations. The role involves overseeing technical programs for Government Programs, ensuring compliance, and managing operational processes related to claims adjudication and regulatory requirements.

Health CareInformation Technology

Responsibilities

Supports annual department budget and staffing plans in support of Navitus’s strategic and business initiatives

Monitors program regulations, guidance, and systems to determine needs and gaps that impact compliance and program operations. Provides direction and oversight for the development, modification and improvement of business processes and policies

Oversees the accurate and timely administration, coordination, reconciliation and reporting of eligibility changes including CMS enrollment submissions for EGWP offering; retroactive Medicare D low-income subsidy eligibility changes; retroactive eligibility changes and impact assessments for Medicaid and Exchange, and changes in the primary and supplemental other insurance file and COB changes

Oversees the processing of all CMS and state encounter data submissions and reconciliations. Ensures PDE, ED, and Exchange encounter submissions and manual and electronic claims adjustments to correct PDE/ED errors and recoveries are handled appropriately and timely. Oversees outcomes adherence to contractual and performance guarantee requirements and creates the vision for and oversees all related projects and process improvements

Oversees and ensure compliance with the Medicare, Medicaid and Exchange claims adjudication and COB regulatory requirements

Oversees and ensure compliance with the Medicare EOB regulatory requirements and administration as well as Medicare M3P administration and vendor management

Oversees and ensure compliance with reprocessing regulatory requirements and timelines

Ensures successful internal and external audits by working with claims adjudication and recoveries teams to maintain compliance with regulatory requirements and requirements for operational and financial controls

Implements new Medicare D, Medicaid and Exchange requirements impacting claims adjudications, RDS, EGWP enrollment, EOB administration, encounter data administration, Medicare Plan Finder, and retro-eligibility requirements

Other duties as assigned