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Director, Health Plan Operations - PACE Elder Service Plan

**Requisition Number:** 10065

**Location:** CHA East Cambridge Care Center

**Work Days:** 8:00am - 4:30pm

**Category:** Professional and Management

**Department:** CHA PACE

**Job Type:** Full time

**Work Shift:** Day

**Hours/Week:** 40.00

**Union Name:** Non Union

About CHA PACE

Cambridge Health Alliance's **Program of All-Inclusive Care for the Elderly (PACE)** is a nationally recognized model of care that serves adults aged 55 and older living with chronic medical and/or mental health challenges.

At CHA PACE, our mission is to support our program participants in achieving the highest level of independence within their communities and preventing nursing home placement. Our high-functioning interdisciplinary team supports this goal by providing fully integrated medical and behavioral health services, community resources, and home-based care in a collaborative and supportive environment.

Position Overview

CHA PACE is seeking a strategic and detail-oriented **Director of Health Plan Operations (HPO)** to lead and manage all insurance and operational aspects of health plan services. This leadership position ensures that our HPO functions meet regulatory standards, support financial and clinical objectives, and serve the best interests of our participants.

This role is responsible for overseeing Medicaid and Medicare enrollment, claims, reporting, risk adjustment, compliance, contract management, and system efficiency, while supervising a high-performing team including a Contracts Manager, Business Analyst, Reporting Manager, Claims Liaison Analyst, and MassHealth Coordinator.

Key Responsibilities

Administrative Oversight of Health Plan Operations

• Lead government relations as they pertain to Health Plan Operations.

• Manage all aspects of Medicare and Medicaid enrollment, retention, dis-enrollment, and long-term care transitions.

• Ensure regulatory compliance with MassHealth renewals and Medicare risk adjustment documentation.

• Oversee Medicare and Medicaid payment systems and performance-based payment models.

• Manage and optimize data systems for enrollment, compliance, and internal reporting.

• Maintain secure and organized HPO data systems (paper and electronic).

Claims and Revenue Reporting

• Serve as lead liaison to Third Party Administrator (TPA) and Pharmacy Benefit Manager (PBM).

• Monitor and manage claim processing, approvals, and pend reports.

• Translate Medicare and Medicaid payment data into actionable formats for finance operations.

Contracts and Vendor Management

• Oversee contracting processes in collaboration with the Contracts Manager.

• Monitor compliance and quality of vendor and agency performance.

• Negotiate contracts to support efficiency and cost savings.

Compliance and Quality Oversight

• Stay current on regulatory and policy changes affecting PACE and HPO.

• Lead internal and external audit preparation and response, including Medicare Part D and Enrollment Data Verification.

• Develop and enforce policies and dashboards aligned with CHA and government standards.

• Deliver training related to HPO regulations, audits, and fraud/waste/abuse compliance.

Strategic Planning and Program Advancement

• Track industry trends in HPO and identify opportunities for innovation and process improvement.

• Build and maintain partnerships with CMS, MassHealth, the National PACE Association (NPA), vendors, and other strategic stakeholders.

• Ensure CHA PACE is positioned for long-term compliance and growth.

Qualifications

Education

• Graduate of accredited College/University with BS/BA required. Equivalent, relevant experience may be substituted for a degree.

• Masters Degree in Health Administration or equivalent desired.

• Microsoft Access coding skills/certification desired.

Work Experience

• Minimum 5 years significant progressively responsible experience in Health Plan Operations.

• At least 3 years management experience required.

• Demonstrated leadership and management capabilities to facilitate effective and efficient operations and support effective relationships with external agencies and organizations.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.

_Cambridge Health Alliance brings Care to the People - including your neighbors, friends and family. Our local hospitals and care centers serve our vibrant, diverse communities, and play an integral role in improving health. As passionate advocates for the underserved, we actively partner with our communities to take on challenging public health issues, and conduct important research to help reduce barriers to care. We believe that everyone deserves access to high quality, convenient health care. This is why our employees believe in where they work and why many build long, rewarding careers at CHA._

_Healthcare is changing rapidly. CHA has a strategic plan that charts a proactive course for our future. It is built on a vision of equity and excellence for everyone, every time. It also recognizes that our workforce is our most valuable asset and prioritizes competitive salaries, benefits and professional development opportunities for employees. The strategic plan is changing the way we provide care and improving the health and experience of our patients; we are looking for smart, committed, compassionate people who want to be part of making our vision of better health and equity a reality._

_At CHA, you can believe in where you work and go home every day knowing you made a difference. Join our team and help us bring Care to the People._