Medica · 1 week ago
Director, Medicare Product Performance
St Louis, Missouri, United States
Full-time
Hybrid
Director/Executive
$130K/yr - $196K/yr
10+ years expMedica is a nonprofit health plan serving communities in Minnesota and beyond, and they are seeking a Director of Medicare Product Performance. This key leader will drive the financial, operational, and competitive success of Medica’s Medicare portfolio, focusing on performance improvement initiatives and ensuring compliance with CMS requirements.
Health CareMedical
No H1B
Responsibilities
Defines and monitors Key Performance Indicators (KPIs) aligned to Medicare bid targets and segment goals; establishes transparent reporting to communicate goals and execution across the organization
Partners with cross-functional teams (network, pharmacy, clinical programs, Stars, risk adjustment, finance, actuarial, operations) to optimize drivers of competitiveness and address outliers
Identifies performance gaps and leads cross-functional remediation plans, ensuring timely execution and measurable improvement
Manages program deliverables and holds matrixed partners accountable for on-time, high-quality completion of priority initiatives
Regularly monitors performance of core KPIs to ensure products are performing as expected:
Financial & Revenue: Premium and risk-adjusted revenue, margin, MLR
Medical & Pharmacy Cost: Trend drivers, utilization, site-of-care optimization, formulary effectiveness, specialty pharmacy
Quality & Risk Programs: Medicare Stars domains, HEDIS/CAHPS, risk adjustment (RAF accuracy), coding completeness
Membership & Market Performance: Enrollment growth, retention/churn, attribution accuracy, product competitiveness
Operations & Member Experience:
Claims: Auto-adjudication rate, financial accuracy, timeliness, inventory/aging, appeal/grievance outcomes
Call Center: First Contact Resolution (FCR), service level, NPS/CSAT, CTM case rate and resolution
Provider Operations: Credentialing throughput, directory accuracy, dispute resolution timeliness
Compliance: Audit readiness, regulatory turnaround times, CAP completion, issue prevention
Sales & Marketing: Distribution performance, AEP/OEP conversion, lead quality, marketing effectiveness, broker engagement
Value-Based Care: VBC attribution, contract performance, incentive alignment, care management impact
Chairs the Medicare Product Performance Governance Committee, setting priorities, cadence, agendas, and driving execution of initiatives that materially influence segment performance
Aligns cross-functional partners – network, clinical, pharmacy, finance, actuarial, operations, and compliance – around Medicare priorities
Partners with the VP/GM, Medicare to develop and execute segment strategy, portfolio optimization, and multi-year roadmaps
Partners closely with business connectivity and data colleagues
Delivers executive-ready insights on threats, opportunities, and infrastructure needs; translates complex data into clear recommendations and decision paths
Proposes structural and operational solutions (e.g., workflow redesign, vendor optimization, benefit configuration changes, product repositioning) and oversees delivery
Contributes to enterprise strategic planning, informing investments and priorities for the Medicare segment
Qualification
Required
Bachelor's degree in Business, Marketing, Strategy, Leadership, or equivalent experience in a related field
10+ years of progressive experience, with 5+ years in leadership roles
Understanding of Medicare Advantage and/or Cost Plan performance levers
Strong financial acumen; adept at interpreting and organizing data then turning it into action
Proven ability to lead through influence, drive cross-functional alignment, and project manage complex initiatives
Exceptional communication / storytelling and executive presence
Strategic thinking and planning, project leadership and execution, and general knowledge of operational platforms and third party capabilities
Benefits
Competitive medical
Dental
Vision
PTO
Holidays
Paid volunteer time off
401K contributions
Caregiver services
Many other benefits to support our employees
Company
Medica
Medica is a company that provides health coverage to meet customers needs for health plan.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Naylor
President and CEO
Jeni Alm
Vice President, Provider Partnerships and Solutions
Recent News
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