Health Plan Manager, Jordan Valley Senior Care (JVSC) PACE in Springfield, Missouri at Advocates For A Healthy Community Inc.

About Jordan Valley Health:

Jordan Valley Health (JVH) is a mission-driven organization dedicated to improving the health of individuals and families in underserved communities. We provide comprehensive healthcare services including primary medical, dental, vision, and behavioral health. Our mission is simple: Improve our community’s health through access and relationships. By working collaboratively with partners and continually innovating, JVH strives to be a leader in providing essential healthcare for the underserved, ensuring everyone in our community has access to quality healthcare.

Job Summary:

The Health Plan Manager is responsible for the comprehensive oversight and management of all health plan operations within Jordan Valley Senior Care (PACE). This position serves as the primary point of accountability for Medicare Part D oversight, financial performance, claims adjudication and processing, and regulatory contracting compliance. The Health Plan Manager ensures that Jordan Valley Senior Care operates in full compliance with applicable federal and state regulations while achieving financial and operational excellence in service delivery to enrolled participants. The Health Plan Manager frequently collaborates with the Finance and Compliance departments. The Health Plan Manager receives final direction and oversight from the Executive Director.

Key Responsibilities:

Medicare Part D Pharmacy Benefit Oversight

• In collaboration with the Clinical Pharmacist, serves as the designated Part D responsible party for Jordan Valley Senior Care, ensuring compliance with all CMS Part D requirements under 42 CFR Part 423 as applicable to PACE.
• Monitor and oversight, in conjunction with pharmacy, Part D reporting obligations, including annual attestations, DIR fee reconciliations, and TrOOP (True Out-of-Pocket) cost tracking.
• In collaboration with the PBM and Clinical Pharmacist, ensure accurate and timely submission of Part D Prescription Drug Event (PDE) records and coordinate correction processes for rejected claims.
• Oversee coordination of benefits (COB) for participants with third-party coverage and ensure proper Part D sequencing for dual-eligible enrollees.
• In conjunction with Compliance, liaise with CMS on Part D audit readiness and respond to Prescription Drug Plan (PDP) compliance inquiries.
• Assist in Part D Bid development and submission in conjunction with the Finance department.

Financial Management & Plan Performance

• In collaboration with Jordan Valley Health’s finance team and the Executive Director, develop, manage, and monitor the health plan operating budget, including capitation revenue, medical expenses, administrative costs, and reserve requirements.
• Analyze monthly and quarterly financial performance against capitation benchmarks (Medicare and Medicaid blended rates) and provide variance analysis to executive leadership.
• Oversee and coordinate data submission to actuaries for benefit packages and coordinate with CMS and the state Medicaid agency during annual rate negotiations and bid submissions.
• Oversee risk adjustment data validation processes in conjunction with the Medical Director to optimize risk-adjusted revenue.
• Oversight the submission of encounter and enrollment data by the TPA.
• Monitor medical loss ratios (MLR), administrative cost ratios, and other key financial indicators to identify trends and corrective opportunities.
• Coordinate with the finance department on month-end close, IBNR reserve calculations, and encounter data reconciliation.
• Works in collaboration with the Finance department, IDT, and participant/caregivers on any participant assistance (i.e. Medicaid spenddown, utility assistance, spend cards, etc.).
• Assist the Finance Department with financial performance reports to the Board of Directors, finance committee, and CMS as required/needed.

Claims Administration & Adjudication

• Oversee all claims processing operations by TPA, including fee-for-service claims from contracted providers, institutional claims, and out-of-network emergency claims.
• Establish and maintain claims processing standards.
• Monitor claims adjudication accuracy rates, denial patterns, and appeals outcomes; implement corrective action plans as needed.
• Supervise the coordination of benefits (COB) process across Medicare, Medicaid, and other third-party payers to minimize duplicate payments and ensure correct primary/secondary payer sequencing.
• Oversee encounter data submission to CMS and the state Medicaid agency, ensuring completeness, accuracy, and timeliness in compliance with RAPS and EDPS requirements.
• In collaboration with Finance and Compliance, manage claims-related audits, including CMS validation audits and state Medicaid audit requests, ensuring complete and accurate documentation.
• Oversee actions of third-party administrator to ensure timely and accurate processing of claims and enrollment data.

Contracting & Network Management

• In collaboration with the Jordan Valley Health contracting team, negotiate, execute, and manage contracts with specialty providers, ancillary service vendors, hospitals, and other healthcare entities on behalf of Jordan Valley Senior Care.
• Ensure all provider agreements meet CMS and SAA PACE contracting requirements under 42 CFR Part 460, Subpart H, including required provisions, delegation oversight, and attestation requirements.
• Maintain a comprehensive contract management system and oversee the contract renewal calendar, ensuring no lapses in executed agreements.
• Conduct ongoing monitoring of contracted vendor and provider performance, including quality metrics, credentialing status, and compliance with PACE-specific care standards.
• Oversee delegation agreements with First Tier, Downstream, and Related Entities (FDRs) and ensure compliance with CMS FDR oversight requirements.
• Coordinate with Compliance for legal counsel on contract interpretation, dispute resolution, and regulatory compliance language.

Regulatory Compliance & CMS Oversight

• In collaboration with Compliance, lead preparation for and management of CMS Program Integrity audits, CMS compliance program effectiveness reviews, and state Medicaid audits.
• Work with Compliance to maintain a robust compliance monitoring program, including internal audits, mock CMS audit processes, and corrective action plan (CAP) management.
• Monitor PACE HPMS (Health Plan Management System), CMS, and actuarial (Milliman and Mercer) reporting obligations.
• Oversee PACE enrollment and disenrollment processes, ensuring compliance with CMS eligibility, marketing, and enrollment rules.

Quality Improvement & Reporting

• Oversee quality improvement (QI) activities related to health plan operations.
• Collaborate with the IDT and clinical leadership to review per-member-per-month (PMPM) claims trends.

Leadership & Staff Management

• Recruit, hire, develop, and evaluate health plan operations staff.
• Establish departmental goals, performance standards, and work plans aligned with organizational strategic objectives.
• Foster a culture of compliance, accountability, and continuous improvement within the health plan operations team.
• Provide mentorship and professional development opportunities to direct reports.
• Promote the education and development of students, interns, residents, apprentices, and other new staff by sharing expertise, responding to questions, and fostering a positive and supportive learning environment.
• Perform all other duties as assigned.

Benefits Overview:

• Medical and Prescription Drug Coverage: Three comprehensive plan options (Buy-up, Base, and High Deductible) through UnitedHealthcare's Choice Plus network, covering various deductibles and out-of-pocket limits. Includes access to telemedicine services via Teladoc.
• Health Savings Account (HSA): Available for employees in the High Deductible Plan with employer contributions and tax advantages.
• Flexible Spending Account (FSA): Options for both healthcare and dependent care FSAs, allowing pre-tax contributions for qualified expenses.
• Dental and Vision Coverage: Dental insurance through Cigna’s DPPO network and vision coverage through EyeMed’s Insight network.
• Retirement Plan: Pre-tax and Roth 403(b) retirement plans with a 5% employer match starting after 30 days of employment.
• Life and Disability Insurance: Basic Life and AD&D insurance provided at no cost, with the option to purchase additional coverage. Long-term and short-term disability insurance are also available.
• Employee Assistance Program (EAP): Free confidential support for personal and professional challenges, including counseling and crisis intervention.
• Additional Voluntary Benefits: Options for critical illness, accident, hospital care, and pet insurance through MetLife.

Holidays:

• Nine paid holidays per year.

Health Requirements:

All employees are required to provide proof of vaccination for Flu, Hepatitis B and Tuberculosis (TB) as part of our commitment to maintaining a safe and healthy workplace.

Application Process:

Interested applicants should submit a resume and cover letter through the JVH career portal at Careers & Education - Jordan Valley. Applications will be accepted on a rolling basis until the position is filled.

Jordan Valley Health is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

Required Qualifications:

• Bachelor’s degree in health administration, business administration, public health, or nursing preferred, or equivalent work experience required
• Minimum of 1-2 years of progressive experience in health plan operations
• Two years in a supervisory or management capacity
• Direct experience with Medicare Advantage, Medicare Part D, Medicaid managed care, or PACE programs required
• Demonstrated experience in health plan contracting, claims operations, or regulatory compliance
• Two years work experience in accounting/finance.
• Either one year of experience working with a frail or elderly population or, in the absence of such experience, receive appropriate training from the JVSC on working with a frail or elderly population upon hire.
• BLS Certification required within 90 days of hire

Preferred Qualifications:

• Master's degree preferred