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Role Description

Navitus Health Solutions is seeking a Director, Technical Operations with no less than 5 years of experience at a PBM, health plan, or managed care environment to join our team! This is not a call center or general operations leadership role.

The Director, Technical Operations (DTO) is responsible for:

• Providing regulatory interpretation, operational expertise, and oversight of technical programs for Government Programs.
• Ensuring compliance with policies, procedures, and CMS and state program requirements.
• Developing, implementing, and monitoring department goals, objectives, processes, and policies.

The DTO will ensure effective, efficient, auditable, and compliant Medicare, Medicaid, and Exchange Claims Adjudication.

Responsibilities

• Supports annual department budget and staffing plans in support of Navitus’s strategic and business initiatives.
• Monitors program regulations, guidance, and systems to determine needs and gaps that impact compliance and program operations.
• Provides direction and oversight for the development, modification, and improvement of business processes and policies.
• Oversees the accurate and timely administration, coordination, reconciliation, and reporting of eligibility changes.
• Ensures compliance with Medicare, Medicaid, and Exchange claims adjudication and COB regulatory requirements.
• Implements new Medicare D, Medicaid, and Exchange requirements impacting claims adjudications.
• Ensures successful internal and external audits by maintaining compliance with regulatory requirements.
• Other duties as assigned.

Qualifications

• Bachelor’s Degree required.
• 5 years’ experience in PBM, health plan, or managed care environment.
• Knowledge and experience in project management, claims adjudication, analytical tools and analysis, and technology solutions.
• Proven track record of process improvement, regulatory compliance, monitoring and metrics, and leading projects and teams.
• Ability to interact cooperatively and respectfully with other employees.

Benefits

• Top of the industry benefits for Health, Dental, and Vision insurance.
• 20 days paid time off.
• 4 weeks paid parental leave.
• 9 paid holidays.
• 401K company match of up to 5% - No vesting requirement.
• Adoption Assistance Program.
• Flexible Spending Account.
• Educational Assistance Plan and Professional Membership assistance.
• Referral Bonus Program – up to $750!