About the role

Aplyr's Quick Take

This role is about leading the operations of the Medicare Advantage program, focusing on compliance, vendor management, and strategic execution. It's a senior-level position that requires overseeing daily operations and ensuring regulatory adherence while driving performance improvements. You'll be managing a team and collaborating with various stakeholders, making it more of a managerial role than an individual contributor one.

Good fit

Ideal candidates will have 5-7 years of experience in Medicare Advantage operations, with a strong background in health plan administration and familiarity with claims processing systems. A strategic thinker who is comfortable with both operational and technical aspects will thrive here.

Worth noting

The role emphasizes the use of AI technologies to improve operations, which may appeal to candidates interested in innovation. However, the requirement for experience with specific systems like FACETS and familiarity with Agile/Waterfall methodologies could be a barrier for some applicants.

Provide end-to-end operational leadership for the Medicare Advantage (MA) program, overseeing day-to-day operations, compliance, vendor management, and strategic execution across the member lifecycle. Drive operational excellence through metrics, governance, regulatory adherence, and continuous improvement while partnering closely with FEP leadership, Plans, IT, vendors, and CMS.

Own MA operational performance, including planning, budgeting, KPIs, SOPs, and team capability development.
Ensure compliant, high-integrity claims and payment operations, including FDR oversight, payment integrity, and fraud, waste, and abuse controls.
Lead business requirements, system implementations, UAT, and change management in partnership with the FEP Operations Center and cross-functional stakeholders.
Apply deep Medicare Advantage regulatory and operational expertise to ensure CMS compliance, audit readiness, Star Ratings performance, and quality improvement.
Drive strategic planning, multi-year operational roadmaps, and process optimization using Lean Six Sigma and industry benchmarking.
Manage vendor relationships, contracts, and RFPs; represent MA operations in governance forums and with CMS.
Support enrollment, member services, provider network operations, ANOC/EOC planning, and member experience initiatives.
Serve as a senior liaison and communicator, presenting recommendations to leadership and mentoring operational staff.

Minimum 5-7 years of Medicare Advantage operational experience
Experience with health plan administration systems and platforms. Experience with Federal Employee Program or federal health benefits programs, preferred
Background in both operational and technical aspects of MA plan administration preferred
Experience working with FACETS claims processing system to manage healthcare claims adjudication, benefits configuration, and member eligibility, ensuring accurate and timely claims processing and resolution.
Experience leveraging AI technologies (machine learning, natural language processing, automation tools) to streamline operational processes and enhance customer experience, resulting in measurable improvements in efficiency, cost reduction, and customer satisfaction.
Familiarity with Agile/Waterfall project methodologies
Proficiency in Microsoft Office Suite, particularly Excel and Visio
Experience with requirements management tools preferred
Demonstrated experience managing vendor relationships, preferably with system integrators
Proven track record writing business requirements and supporting system implementations
Experience working in health plan operations or similar healthcare environment
Comprehensive understanding of Medicare Advantage regulations, CMS requirements, and compliance standards (including Star Ratings, RADV, risk adjustment)
Strong vendor management and contract oversight capabilities
Excellent business analysis and requirements documentation skills
Strategic thinking with ability to transition from tactical execution to long-term planning
Proficiency in process improvement methodologies (Lean, Six Sigma)
Strong project coordination and organizational skills with ability to manage ambiguity
Exceptional written and verbal communication abilities
Proven ability to influence without authority and build consensus
Change management and organizational development capabilities
Ability to manage multiple priorities in a fast-paced, dynamic environment
Previous experience in a matrixed organizational structure preferred
PMP, PGMP, CBAP, or similar professional certification preferred
Knowledge of healthcare data standards (HIPAA, X12, HL7) preferred

The posting range for this position is $141,000 to $180,000.

#LI-Hybrid

The posted salary range is the lowest to highest salary we, in good faith, believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the hiring range and this hiring range may also be modified in the future. A candidate’s position within the hiring range may be based on several factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, and business or organizational needs. This job is also eligible for annual bonus incentive pay.

We offer a comprehensive package of benefits including paid time off, 11 holidays, medical/dental/vision insurance, generous 401(k) matching, lifestyle spending account and many other benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Aplyr's read

Blue Cross Blue Shield is a collective of independent health insurers, ideal for professionals passionate about community health and complex regulatory environments.
Synthesized from recent postings & public sources

What's promising

•BCBSA offers diverse roles in policy, data science, and healthcare solutions.
•Strong focus on community-based health initiatives and local operations.
•Opportunities to work on advanced projects in AI and cybersecurity.

What to watch

•Complex organizational structure with 36 independent entities may lead to bureaucratic challenges.
•Navigating regulatory environments can be demanding and intricate.
•Limited public information about internal culture and employee satisfaction.

Why Blue Cross Blue Shield

•Federation model allows for localized decision-making and community engagement.
•Significant involvement in federal and state healthcare policy development.
•Pioneering roles in healthcare data science and artificial intelligence.

Aplyr’s read is generated by AI from public sources. Was it useful?

About Blue Cross Blue Shield

Blue Cross Blue Shield

bcbs.com

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The Blue Cross Blue Shield Association (BCBSA) is a federation of 36 independent, community-based and locally operated Blue Cross and Blue Shield companies. It provides health insurance coverage to millions of Americans.