The Director of Enrollment and Payment is responsible for oversight, directing, leading and enhancing enrollment management, revenue management and reconciliation, premium billing, and provider capitation processing for Senior Products. The Director is responsible for oversight and directing the development, implementation and maintenance of systems, policies, and procedures for Membership Operations and for ensuring CMS, DOI and EOHHS requirements are achieved. This function is highly complex and has a high level of both internal and external visibility.
The Director is accountable for the assessment, monitoring, and oversight of all compliance activities within the Membership Operations department and works collaboratively with Corporate and Operations Compliance leadership. The Director will be expected to represent THP and interface with state and federal regulatory agencies and will demonstrate subject matter expertise in the area of compliance and regulatory requirements that govern Membership Operations.
The Director is also responsible for ensuring consistent compliance with CMS regulations, timely and accurate billing, reconciliation, and reporting of over $1.1 million in annual receivables.
There is a high level of operational and compliance management complexity inherent in this position. The Director will be responsible for making decisions that impact several major departments, the division, and may impact enterprise short- and long-term goals. Decisions are very difficult to correct or implement and may require cooperation of divisions outside the incumbent's sphere of influence.
Responsible for management of all aspects of a complex vendor relationship which requires an expert understanding of complex processes and systems.
- Performance Management: Measure, report, and review the services provided by the vendor
- Relationship Management,: Oversee activities to ensure alignment between the organization's needs, and what the vendor delivers
- Technical Management: Oversee the vendor's compliance with specifications provided by the organization
- Contract Management: Manage the contractual relationship between the vendor and the organization, including financial and staffing concerns
This is a highly visible and complex function that requires expert understanding of all aspects of the process and compliance implications. Solutions frequently require anticipation and a unique approach. Significant and sometimes uncharted research guided by broad policies must be conducted to identify solution.
- CMS: Ensure that THP receives all CMS revenue (Part A, B and D) in a timely manner and that proper membership and payment accounting and reconciliation processes and reporting are in place and consistently functioning.
- EOHHS: Ensure that THP receives all EOHHS revenue for duals membership (Senior Care Options) in a timely manner and that proper membership and payment accounting and reconciliation processes and reporting are in place and consistently functioning.
- Develop, establish, and consistently maintain monthly analysis and reconciliation of membership and payments. Proactively identify membership and payment issues and opportunities and aggressively work to resolve.
- Develop process and methodology to track and reconcile expected CMS receivables including special adjustments, retroactive eligibility changes, coordination of benefits/Medicare secondary payor revenue reduction, etc.
- Develop and maintain contacts within CMS regional and central office and EOHHS to support issue resolution and ongoing communication.
- Develop, maintain, and distribute monthly management reporting of key membership and payment metrics.
- Non- CMS: Oversee the monthly premium billing processes for individuals and groups ensuring the accuracy and timeliness of invoicing and reporting. Oversee reconciliation, management, and reporting of individual and group receivables is completed monthly and adheres to Tufts Health Plan standards for receivables management
This function requires collaboration with constituents at all levels of the organization including senior leadership.
- Fully understand all CMS reporting and how it can be used to reconcile payments, identify issues and opportunities. Educate others on its potential uses.
- Fully understand all EOHHS reporting and how it can be used to reconcile payments, identify issues and opportunities. Educate others on its potential uses.
- Maintain and promote within the department, and with others in the company, a deep understanding of CMS payments, reporting, and implications for THP and providers.
- Collaborate and routinely communicate with key constituents (Finance, Treasury, Actuarial, Risk Adjustment Ops and Senior Management) status of monthly payment issues and reports.
This is a complex function requiring process and technical skills. The impact of this work could have significant impact on the division's overall performance. Problems encountered are large and complex in scope. Solutions frequently require anticipation and a unique approach.
- Oversee the ongoing processing of Senior Products enrollments, disenrollments, and member data changes to ensure compliance with all CMS regulations and accurate reporting of membership data to CMS.
- Oversee the ongoing processing of the 834 enrollment file from the state for duals
- Ensure appropriate support of members and THP departments to identify and resolve member issues regarding enrollment/disenrollments.
Ensure the timely and accurate set up of provider group payment rates and the processing of monthly capitation payments, reconciliation, and reports to providers and corporate finance.
Requires expert understanding of processes and supporting technology Significant and sometimes uncharted research guided by broad policies must be conducted to identify solutions.
- Stay abreast of CMS, industry, and THP trends; regularly review the appropriateness of processes, infrastructure, and reporting, and refine as business needs change.
- Manage an annual budget. Champion aggressive performance management.
- Chair or participate in work groups concerning policy issues that impact operations and service to members.
- Participate in the identification of IS and Non-IS infrastructure, processes, and system enhancements to support the growth of membership, to improve operating efficiency, and to improve financial accountability.
- Oversee regulatory compliance activities across all enrollment and payment functions.