Senior Manager, Medicare Plans - CFHP

Position Summary/Responsibilities

Serves as a key leader in driving positive change and fostering a culture of continuous improvement within the organization’s Medicare programs’ regulatory and compliance delivery. Responsible for working in collaboration with Community First leaders in developing, implementing, and supervising initiatives to enhance the quality of care and outcomes for Medicare members while ensuring rigorous compliance with all relevant Centers for Medicare & Medicaid Services (CMS) regulations and guidelines. Collaborates closely with various internal and external stakeholders to achieve organizational performance goals. Tracks improvement efforts and monitor ongoing clinical processes. Provides comprehensive updates to management on the achieved results, ensuring transparency and accountability in driving organizational excellence.

Education/Experience

A Bachelor’s degree in nursing is required, with a preference for a Master’s degree in a health-related field. A thorough knowledge of health care regulations from the Texas Department of Health and Human Services (HHSC) and the Centers for Medicare & Medicaid Services (CMS) and familiarity with various accreditation standards, particularly NCQA and HEDIS, is required. Additionally, expertise in policy formulation, quality management, and process improvement is required. Knowledge of analytical and investigative techniques sufficient to identify current methodologies and evaluate the results’ effectiveness is required. Strong project management skills and proficiency in data management are required. A minimum of five years of managed care experience with working experience in Medicare programs is required.

Licensure/Certification

Current Registered Nurse license to practice professional nursing issued by the Board of Nurses Examiners for the State of Texas is required. Certification by a nationally accrediting body in health care quality is preferred.