Health Plan Manager, Jordan Valley Senior Care (JVSC) PACE

Description

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 collabo