Aetna Director, Medicare Operations in Plymouth, Minnesota

Req ID: 52204BR

Allina Health and Aetna are building a team to support a new joint business venture. Allina Health | Aetna is a jointly owned health plan company that will rethink, reimagine and redefine the health care system to reward value more than volume and help create quality outcomes and healthy days for Minnesotans. We are seeking a Director of Medicare Operations who will report to the Medicare General Manager and will drive day-to-day operational and implementation activities for the joint venture s Medicare products.


In support of the General Manager, the incumbent has responsibility for the implementation of all MAPD activities and programs across a market to achieve all earnings and growth objectives. Provides guidance and consultation for new product start-up, program design and regulatory compliance. Leads MAPD operational interface and ensures strategic and tactical business goals are achieved across the organization. Responsible for all CMS, Bid and application activities.

The Director, Medicare Operations will manage all aspects of operational activities related to Medicare in the Minnesota Market.

Fundamental components: Directs operational functions of Medicare products across a marketResponsible for the oversight and execution of all CMS required activities and processes including the accuracy and compliance of the annual bid application, expansion application, member materials, and group set up.Facilitates internal and external Medicare audit activity including CMS and operation integrity audits. Coordinates file pulls, data requests, universe development, and supporting documentation.Maintains awareness of trends, developments, and governmental regulations in Medicare and managed health care organizations.Responsible for Medicare product design features, integration schedule, and operational readiness for existing and new product start-ups.Participates in various committees to represent the Medicare department including NCQA, Internal Research, UM, QI, Trend/MER, Risk Mitigation, Complaint and Appeals, bid, implementation, migration, etc.Leads member retention activities, including development of outreach material, design/implementation of outreach programs both directly and in coordination with corporate member retention team, development of talking points/educational pieces about market specific issues.Monitors sales and marketing activities to assure adherence to State and Federal regulations.Uses competitive intelligence to guide, consult, and drive product implementation and strategic focus for MAPD.Coordinates strategies and recommends policy positions with senior management regarding legislative issues and regulatory with a key support function in program and project management in support of MAPD, including STARS and Revenue Management, Quality, and Network concerns.Develops and implements business strategies to provide accurate and proactive customer service to members, plan sponsors, and brokers. Provides operational support for market management of plan sponsors, members, and network providers.BACKGROUND/EXPERIENCE desired: Significant (7+ years) experience in Medicare operations and/or product development.Familiarity with regulations and statutes impacting the Medicare business.Ability to perform analysis and legal research to identify and clarify issues.Business acumen and experience with managing complex processes.


The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.


Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.

We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.

Together we will empower people to live healthier lives.

Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.

We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.

Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

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Job Function: Management