Manager, Medicaid Strategic Initiatives Job at Healthfirst

New

Associate Director Access & Reimbursement

The Associate Director of Access & Reimbursement is responsible for leading the ...

Location

United States

Salary:

210000.00 - 250000.00 USD / Year

The Muse

Expiration Date

Until further notice

Requirements

Bachelor's Degree required, in Business, Health Policy, or Life Sciences preferred
AAPC coding courses / or equivalent a plus
10+ years of relevant experience in the pharmaceutical healthcare sector
5+ years in the vaccine payer space
Experience in working with US payers
Experience in billing /coding for both buy & bill products (medical) & pharmacy billing PBM (drug benefit) (strongly preferred)
Strong leadership skills and demonstrated ability to lead cross functionally
Deep understanding of Commercial, Medicare, and Medicaid and how it pertains to Influenza vaccine coverage and payment
A proven track record of successful account management and executing national strategies
Demonstrated results in the area of GPO, health system, retail, wholesaler/distributor with vaccine reimbursement vs general Pharma

Job Responsibility

Enact key strategic initiatives to help facilitate CSL Seqirus to achieve / exceed specific sales volume, revenue, and profitability targets
Leads CSL Seqirus interactions with all payers. Fosters and develops multi-level and senior relationships to create a foundation for developing a pathway to effectively communicate CSL Seqirus story
Analyze payer access and reimbursement (medical & drug) landscape for near-term and longer-term objectives. Provide insights on the analysis to create change in the organization. Using pareto mentality develops strategies and tactics to ensure positive change. Develops a customized approach for each payer to most effectively influence change. Reports timely feedback regarding account interactions and next steps
With relationship depth and breadth of customer interaction at various (senior management clinical / financial / operational) levels of the customer's organization, builds and maintains relationships with key individuals to enable market access of CSL Seqirus vaccines, developing a favorable environment for pull-through at the national, regional, and local provider levels. Develops and sponsors key programs which address customer needs and enhances the customer value perception of CSL Seqirus
Convinces internal and external stakeholders about the value of the CSL Seqirus Customer Experience vision
Acts as the voice of the customer with internal stakeholders to build Seqirus' acumen on customer challenges
Develops and executes business solutions at customers that help enhance CSL Seqirus' partnership within CSL Seqirus primary channels
Provides expertise to the organization as an SME in regards to reimbursement at national and regional level and ensures CSL Seqirus products have market access at all National and select Regional health plans and PBMs. Has effective strategies in place when there are coverage issues by being able to connect with key payer decision makers immediately to fix coverage issues
Works with internal and external stakeholders to enhance CSL Seqirus position in the market
Identifies areas of opportunity for CSL Seqirus growth and directs the organization to implement in an efficient manner

What we offer

Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Short-Term Disability
Long-Term Disability
FSA
HSA
Mental Health Benefits
Adoption Leave

Fulltime

Domain Transformation Lead (Business-Technology) - Health Plan / Payer

The Technical Product Manager (TPM) II serves as a strategic bridge between busi...

Location

United States , Los Angeles

Salary:

121056.00 - 199742.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Bachelor's Degree in Computer Science or Related Field
At least 6 years of experience in a health plan, payer organization and/or health system, ideally as a Technical Product Management or similar role that bridges the business and IT
Experience in at least one of the following healthcare domains: Customer Engagement / Front Office Operations
Health Services Delivery & Quality Oversight
Provider Network Operations / Data
Finance / Claims / HR / Compliance Enablement
Proven experience translating business needs into clear problem statements that enable technically ready requirements for IT and development teams
Experience delivering enterprise digital solutions that improve member and provider experience, operational efficiency, and maintain regulatory compliance
Experience with agile product management frameworks, backlog prioritization, sprint planning and related tools, including prior exposure to health plans or health system digital solutions
Experience collaborating with cross-functional business and IT teams to drive enterprise solution delivery and ensure alignment with organizational priorities

Job Responsibility

Collaborates with stakeholders to define the product vision, solution intent, scope, and roadmap within the assigned domain cluster, ensuring initiatives are aligned with strategic objectives, measurable business outcomes, and consistent value delivery across related business functions
Leads the creation of clear problem statements and desired outcomes from complex business needs within the domain cluster, enabling technically ready requirements for IT and development teams
Ensures requirements are accurate, complete, timely, and aligned with defined success metrics to support cluster-level product strategy
Collaborates with business and IT stakeholders and to ensure solutions meet the business intent of the cluster and align with reference architecture and governance standards
Evaluates technical dependencies and trade-offs within the cluster and ensures requirements are technically ready
Supports backlog prioritization with Business Owners for initiatives within the cluster, participates in sprint planning and review sessions, and facilitates alignment to support successful execution of cluster-level initiatives
Participates in solution delivery activities to ensure alignment with business intent, success metrics, and regulatory requirements
Monitors product performance within the domain, identifies improvement opportunities, and leverages data and analytics to validate outcomes and inform enhancements
Collaborates with IT and business partners to ensure solutions within the domain comply with Health Insurance Portability and Accountability Act (HIPAA), Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), and other relevant regulatory requirements
Partners with business owners, leaders, and subject matter experts (SMEs) to ensure technology delivery aligns with domain initiatives

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Lead Director, Network Management

We're building a world of health around every individual — shaping a more connec...

Location

United States , Work at Home

Salary:

100000.00 - 231540.00 USD / Year

CVS Health

Expiration Date

June 27, 2026

Requirements

A minimum of 10 years related experience and expert level negotiation skills with successful track record negotiating contracts with large or complex provider systems
Demonstrated experience in Medicaid provider contracting, including negotiating, executing, and managing agreements with hospitals, physician groups, and ancillary providers
Hands-on experience with Behavioral Health (BH) network development and contracting, including providers across inpatient, outpatient, and community-based settings
Proven ability to manage the end-to-end contracting lifecycle (negotiation, redlining, implementation, and ongoing relationship management)
Strong knowledge of Medicaid regulations, state requirements, and network adequacy standards, with the ability to ensure compliance across market
Experience developing or supporting value-based arrangements and reimbursement models within Medicaid and Behavioral Health populations
Demonstrated ability to build, manage, and grow strategic relationships that advance long-term organizational goals
Experience presenting complex information to groups in a clear, concise, and persuasive manner, adapting style and content to audience needs

Job Responsibility

Developing strategic partnerships for the Kentucky Medicaid Health Plan
Designing conceptual models, initiative planning, and negotiating high value contracts with the most complex and challenging hospital systems, integrated delivery systems and large groups
Maintaining and enhancing provider networks
Building strong relationships with providers
Developing and executing contract strategies
Negotiating and managing various value based payment models and management of contract performance
Recruiting providers as needed to ensure attainment of network expansion and adequacy targets
Identifying and managing cost issues
Collaborating cross functionally to execute significant cost saving initiatives
Promoting collaboration with internal partners

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs
Bonus, commission or short-term incentive program
Equity award program

Fulltime

Executive Director, Service Operations – Medicaid Contact COE

We’re building a world of health around every individual — shaping a more connec...

Location

United States , Hartford

Salary:

131500.00 - 303195.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

Approximately 10+ years of progressive leadership experience in service operations or contact center environments
Prior experience within a large health plan, managed care organization, or payer environment preferred
Proven success leading large, complex operations, including responsibility for 500+ colleagues across multiple geographies
Demonstrated experience leading transformation initiatives within contact center or service operations (e.g., workforce optimization, member experience redesign, technology enablement)
Strong understanding of Government Programs will be valued
Experience managing multi-million-dollar budgets with strong operational and financial acumen
Demonstrated ability to establish and manage KPIs at scale and drive performance outcomes
Experience partnering with Technology organizations
Familiarity with modern contact center platforms (e.g., GPS (Guided Personal Service) will be valued
Passion for leveraging AI and digital capabilities to enhance service delivery and member experience

Job Responsibility

Setting the strategic direction and driving performance across a complex, high-volume service organization of 500+ colleagues in a work-from-home environment
Designing and executing a forward-looking service operations strategy aligned to enterprise priorities, the evolving regulatory landscape, and the unique needs of Medicaid populations
Partnering closely with Medicaid Plan CEOs and senior leadership to ensure alignment on service delivery, member experience, and operational outcomes
Working in close collaboration with the Technology Center of Excellence to advance digital capabilities, automation, and AI-driven solutions across the contact center
Establishing policies, programs, and operating models that support financial, operational, and service objectives
Leading end-to-end service operations processes and ensuring alignment with broader business strategy
Developing data-driven insights, forecasting, and financial plans to optimize performance
Overseeing large-scale operational initiatives, including transformation efforts, organizational design, and continuous improvement of service delivery
Driving a culture of accountability, empowerment, engagement, and high performance through strong people leadership, clear communication, and disciplined performance management
Ensuring consistent delivery against service standards, enhancing quality and efficiency, and elevating the overall member experience

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs
Bonus, commission or short-term incentive program
Equity award program

Fulltime

Director, Utilization Management

The Director of Utilization Management is a transformational clinical operations...

Location

United States , New York

Salary:

127500.00 - 236555.00 USD / Year

Healthfirst

Expiration Date

Until further notice

Requirements

Bachelor’s degree in healthcare, business, or a related field from an accredited institution or equivalent work experience
Progressive leadership experience in healthcare management including work experience in a mid-senior management role
Work experience and deep familiarity of health plans such as Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP).
Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations
Work experience interpreting and operationalizing regulatory updates and guidance from DOH and CMS.
Work experience demonstrating written and verbal communication skills with the ability to influence and collaborate across all levels and functions.
Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment.

Job Responsibility

Provide strategic direction and leadership to UM leaders and teams executing department functions including prior authorizations, concurrent reviews, and service requests
Develop strong operational and leadership capabilities within the organization through performance improvement, career development, and coaching
Develop and implement policies and procedures that align with industry standards, payer guidelines, and regulatory requirements
Deliver on Healthfirst’s Mission by ensuring optimum quality of member care in a cost-effective manner
Ensure UM operations meet regulatory requirements set forth by CMS, New York State Department of Health (DOH), and other oversight entities
Develop and monitor appropriate metrics to maintain and improve department performance
Collect, analyze, and report on utilization trends, patterns, and impacts to identify areas for improvement
Lead initiatives to improve efficiency, cost-effectiveness, and quality in the UM program, sometimes through the implementation of new technology
Serve as the operational subject matter expert on business development efforts related to UM programs, including the launch of new products or regulatory initiatives
Collaborate closely with other Operations leaders including but not limited to Care Management, Clinical Eligibility, Behavioral Health, and Appeals and Grievances teams to align utilization decisions

What we offer

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

Fulltime

Manager, Utilization Management Claims Review

The Manager, Utilization Management Claims Review is responsible for overseeing ...

Location

United States , Los Angeles

Salary:

117509.00 - 188015.00 USD / Year

L.A. Care Health Plan

Expiration Date

Until further notice

Requirements

Bachelor's Degree in Nursing
In lieu of degree, equivalent education and/or experience may be considered
At least 6 years of experience in Clinical Nursing
At least 3 years of experience with Medi-Cal and Medicare in a managed care environment
At least 4 years of leading staff, supervisor/management experience
Experience in performing and creating clinical documentation
Experience in regulatory compliance for a health plan
Experience leading teams, projects, initiatives, or cross-functional groups
Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement
Registered Nurse (RN) - Active, current and unrestricted California License

Job Responsibility

Manage staff, including, but not limited to monitoring of day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others
Ensure quality standards are met by regularly reviewing claim files, clinical decisions, and Provider Dispute Review (PDR) determinations to confirm compliance with company policies, clinical guidelines, and regulatory requirements
Identify trends or errors and implement improvements to increase accuracy and consistency
Establish team goals, monitor performance metrics, and ensure productivity and quality standards are met
Support recovery efforts and corrective action plans related to inappropriate billing or utilization patterns
Oversee workflow and queue management to ensure claims and PDR requests are completed within required regulatory timeframes, including monitoring workload distribution
Ensure adequate staffing resources and prevent backlogs or compliance risks
Ensure clinical policies are applied correctly and consistently, including policies designed to prevent fraud, waste, and abuse (FWA)
Potential FWA concerns are identified and escalated in partnership with Compliance and the Special Investigations Unit (SIU)
Support audits, regulatory readiness, and cross-functional initiatives to maintain compliance with state, federal, and accreditation standards

What we offer

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

Fulltime

Senior Manager, Corporate Compliance

We’re building a world of health around every individual — shaping a more connec...

Location

United States , New Albany

Salary:

75400.00 - 165954.00 USD / Year

CVS Health

Expiration Date

Until further notice

Requirements

7+ years experience in Medicare or Medicare Advantage government healthcare program compliance or regulatory work
2+ years of Project Management experience
Ability to travel up to 10%
Bachelor's Degree required
equivalent work experience may substitute

Job Responsibility

Serve as market compliance officer for assigned Special Needs Plans (SNPs)
Track, analyze, research, interpret, communicate and monitor applicable CMS and state regulations and government contract requirements to develop recommendations, direction, and escalation ensuring Aetna’s that implementation and integration of program requirements complies with federal and state specific program requirements and the CVS Code of Conduct
Lead and implement an effective Compliance Program as described in CMS Medicare Managed Care Manuals/regulations, applicable Medicaid rules and government contracts, including risk assessment, auditing and monitoring and corrective action oversight
Develop and manage compliance strategies, programs, and processes that promote compliant and ethical behavior, meet regulatory obligations, and prevent, detect, and mitigate compliance risks
Maintain in-depth working knowledge and expertise in Medicare, Medicaid and State requirements, regulations and contracts with a focus on supporting special needs plans
Support and/or facilitate multiple compliance and contract related communications, activities and interactions with regulators, including meeting with regulators on compliance with laws and regulations, developing or assisting in the development of appropriate and strategic written responses to compliance-related regulatory inquiries requiring an understanding of business processes and regulatory requirements and positive relationships with regulators
Leads and/or support numerous external regulatory review and audit activities, including the preparation for and management of external audits conducted by CMS and state Medicaid and related agencies or partners in conjunction with health plan leadership through final report and corrective action plan closure
Builds and maintains positive relationships with internal and external constituents at senior levels to drive decision-making and influence ethical and compliant outcomes
Monitor and audit as outlined in Medicare Compliance Work Plan and direct other projects as assigned to evaluate compliance, propose remediation where necessary and monitor implementation of corrective action
Utilize and maintain current information in systems unique to job functions, such as Microsoft products and compliance specific tools such as Archer

What we offer

Medical, dental, and vision coverage
Paid time off
Retirement savings options
Wellness programs
Bonus, commission or short-term incentive program
Equity award program

Fulltime

Director Government Relations & Advocacy

This position is accountable for the direction, leadership, and strategic and op...

Location

United States , Madera

Salary:

91.35 - 110.58 USD / Hour

Valley Children's Healthcare

Expiration Date

Until further notice

Requirements

Bachelor's Degree In related field (required)
Master's Degree In related field (preferred)
California Drivers License - Other (required)
Car Insurance - Other Valid license and automobile liability insurance coverage with minimum limits as required by state law (required)
Minimum five (5) years Related work experience (required)
Minimum five (5) years Leadership experience (required)
Possess excellent facilitation, presentation and written/verbal communication skills
Working knowledge of the medical industry, including reimbursement, medical technology, case mix, managed care organizations, demographics, financial modeling, statistics, and local/national healthcare trends preferred

Job Responsibility

This position is accountable for the direction, leadership, and strategic and operational elements of Government Relations and Advocacy
Leads and executes a comprehensive government affairs strategy for Valley Children's, a pediatric healthcare system, by monitoring, analyzing, and reporting on federal and California legislation, regulatory activity, and budget developments impacting children's hospitals, including Medicaid/Medi-Cal, behavioral health, workforce, reimbursement policy, and key funding streams
Serves as the primary liaison to federal, state and local government affairs consultants, ensuring alignment with organizational priorities and advocacy goals, while building and maintaining strong relationships with Members of Congress, California state legislators, key committees, and regulatory agencies
Coordinates with national and state hospital associations to advance legislative and regulatory priorities, and represents the organization in coalition efforts, grassroots advocacy, and related engagements
Oversees policy development activities including drafting testimony, regulatory comments, and executive briefing materials, while tracking and influencing rulemaking through CMS and the California Department of Health Care Services
Organizes legislative meetings, site visits, and advocacy campaigns, and partners internally to identify federal funding opportunities and support initiatives related to community health, health equity, and strategic policy impact

Fulltime

Select Country

Manager, Medicaid Strategic Initiatives

Job Description

Job Responsibility

Requirements

Nice to have

What we offer

Looking for more opportunities?