Director, Medicare Strategy

Director of Medicare Strategy


Reports To: Senior Vice President of Provider Services/Network Development/New Programs Integration

Other Key Relationships: Medical Management, Public Policy, Payer Programs, Business Process Operations, Compliance and Legal, Provider Relations & Contracting, Finance, key agency regulators and stakeholders (state and federal), CHNW Leadership

FLSA: Exempt


The Director of Medicare serves as the primary point of accountability for CHPW’s Medicare product line. The Director is the subject matter expert in all areas related to Medicare. Develops Medicare health plan strategy for current and future service areas and needs. Develops, implements, and administers Medicare support systems, policies and standards that ensure compliance, efficiency and effectiveness of Medicare enrollment, claims, customer service, risk adjustment, quality (including Star ratings). Drives performance in a matrix environment, working across all departments and with key stakeholders.


• Leads and partners with key stakeholders on the strategic and tactical planning, development execution and evaluation of key operational elements/programs for the Medicare Advantage product line (e.g., risk adjustment, product design), from identification through execution.
• Designs and recommends innovative programmatic solutions via collaboration with staff at all levels of the health plan, ranging from fine tuning of existing processes to conceptualizing new, cutting-edge ideas.
• Facilitates, monitors and troubleshoots activities with internal and external stakeholders to plan and achieve successful implementation and outcomes.
• Works in collaboration with the Medical Directors and Quality Department to implement and improve clinic-dependent programs related to plan risk adjustment and Star ratings (e.g., chronic condition management, accurate diagnosis coding, provision of preventive services, member satisfaction) through collaboration with clinic leadership, including frequent communication via email, phone, webinar and in-person site visits.
• Advanced and up-to-date knowledge of CMS applications, materials, and rules (e.g., CMS Marketing Guidelines, HPMS memos.
• Actively leads and designs and prices products in partnership with the CFO, actuarial staff and through contracted consultants, incorporating input from key stakeholders and leaders of the organization.
• Participates on key strategic development of other areas of health plan business, including Medicaid, Health Benefit Exchange, and Accountable Care Organizations.
• Oversees the staffing, management, training, development, and performance for assigned staff.
• Provides timely feedback, coaching and training opportunities to foster a successful team and individual career development.
• Other duties as assigned.


• BS/BA degree in Public Health, Health Services, Health Administration or Business Administration, or an equivalent combination of education and highly relevant experience required.
• Master’s degree in health administration, health services planning, public administration, business administration or related field preferred.

Prior Related Experience

· Minimum of seven (7) years of experience with Medicare Advantage at increasing levels of responsibility.
• Minimum of five (5) years of experience leading and managing teams.
• Experience functioning in a strategic role, ideally while leading Medicare strategy across functional areas.
• Experience managing multiple projects/tasks. Proven history of successful results in managing issues and driving strategic program initiatives.
• Experience working as a Subject Matter Expert in a matrixed organization, working with various departmental leads and/or stakeholders.
• Community Health Center delivery system experience preferred.
• Experience in product evaluation, strategic and financial analysis, and contract compliance in the health care industry, specifically with Medicare Advantage.

Employment Eligibility:
• Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.

Knowledge, Skills, and Abilities

• Advanced knowledge of Medicare Advantage programs
• General knowledge of state and federal health care laws
• General knowledge of health plan operations
• Knowledge of government payer contracts
• Strong understanding of systems thinking and how processes are linked
• Demonstrates commitment to the Mission and Values of CHPW and CHNW

• Superior analytical, organizational and problem solving skills.
• Demonstrated experience using Microsoft Office Suite at an intermediate level.
• Demonstrated exceptional communication (verbal and written) skills, including editing written content required
• General project management, prioritization and organizational skills to adhere to deadlines and meet deliverables required
• Attention to detail
• Presentation skills required

• Demonstrated ability to interpret healthcare and financial data and effectively present sophisticated analysis and findings to both subject matter experts and lay audiences.
• Proven ability to think strategically and to translate strategic directives into tactical initiatives.
• Proven ability to drive cross-functional teams to deliver operational compliance.
• Adept at understanding complex concepts and situations presented by the business environment.
• Ability to assess complex problems and provide the appropriate compliance solutions.
• Ability to effectively lead others in times of change and ambiguity, and to engage others in ways that ensure buy-in and commitment.
• Demonstrated ability to effectively lead and facilitate teams.
• Effectively work collaboratively in an interdisciplinary team
• Ability to maintain a professional demeanor and confidentiality.
• Sensitivity to the needs of every individual to be treated with respect and fairness.
• Proven ability to build and strengthen working relationships, and effectively interact with all levels of staff, management and key stakeholders.
• Ability to work independently.
• Ability to adapt in a dynamic and matrixed environment.
• Current/valid WA state driver’s license with ability to travel, including overnight trips.


Sensory :

· Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical :

· Extended periods of sitting, computer use, talking and possibly standing.

· Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.

· Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.

Mental :

· Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability


Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.


Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role. All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164. In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community Health Plan policies can be cause for termination.

PHI is defined at 164.103 as:

“Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.

Individual means the person who is the subject of protected health information.

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.

This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:
• Frequent – The position has frequent and/or daily access and responsibility for PHI. Need to know.

In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.

The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

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