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Dir I Medicare Operations

  • Job Family: Business Support
  • Type: Full time
  • Date Posted:
  • Req #: JR67906





Dir I Medicare Operations

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations (

Indianapolis IN, Harrisburg PA, Syracuse NY, Portland ME, Hingham MA, Atlanta GA, Baltimore, MD, Cincinnati OH, Richmond VA.)

The Dir I Medicare Operations is responsible for directing multiple business function operations teams on Tier I contract with primary responsibility for Medicare appeals process. Responsible for Quality Assurance as it relates to appeals determinations, response to Internal Audit results, Workforce Management and ensuring that all parties are in compliance with Federal laws and regulations for National Government Services (NGS) for Tier I contracts.

How you will make an impact:

  • Manages the performance of compliance to determine the adequacy of the internal controls and identifies workflow efficiencies by using the Appeals’ Quality Assurance Surveillance Plan (QASP) used by CMS to evaluate performance on the contract.

  • Ensures deficiencies in compliance are identified and recommendations are prepared as necessary to strengthen the control environment.

  • Drives innovation throughout the assigned business function areas to reduce the overall costs associated with performing the CMS statement of Work requirements. 

  • Has frequent and regular contact with various representatives of CMS and peer contractor staff. Hires, trains, coaches, counsels, and evaluates performance of direct reports.

Minimum Qualifications:

  • Requires a BA /BS in a related field and minimum of 7 years professional/leadership experience with CMS, including strategic planning, project management, Medicare or related healthcare insurance or medical policy field,  minimum of 3 years management experience; or any combination of education and experience, which would provide an equivalent background.

  • Moderate travel is required.

  • “This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years.”

Preferred Skills, Capabilities and Experiences:

  • Fundamental knowledge of the medicare program as well as the medicare appeals’ process.

  • Robust multitasking skills as it pertains to the different aspects of medicare appeals

  • ability to manage fluctuating workloads and adhere to CMS timeliness standards

  • Ability to engage primary customer (CMS) regarding the current status of the appeals workload in conference calls and face to face presentations.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

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