Job Description Summary
Responsible for developing, establishing, and maintaining the Federal Employee Program (FEP) business policy on Other Party Liability (OPL) contractual activities, as detailed in our contracts with the Office of Personnel Management (OPM), and reimbursement to federal health programs, as defined by regulation. This position is charged with maintaining strategic leadership direction by serving as the single point of contact on complex policy and reimbursement positions for the FEP. Successful execution on the position responsibilities requires ongoing cross-departmental, cross-organizational collaboration and coordination with external federal agency partners to ensure that the FEP strategic direction is established and followed. The establishment and maintenance of contractually sound policy guidance on both current and emerging issues which impact OPL and FEP claims payments by Plans is critical to the accurate application of member benefits and claims adjudication.
Responsibilities include but are not limited to:
- OPL Policy/Data Analytics-Directs policy development to ensure successful compliance with OPM contract provisions, federal law, and regulation on: OPL, including coordination of benefits (COB) with Medicare and other commercial coverage, Workers Compensation, Subrogation, and "No-fault" activities / FEP reimbursement to federal program entities governed by Indian Health Service (IHS), Department of Defense (DoD) and Veterans Affairs (VA) agencies / FEPOC claim/enrollment changes to support contractual and regulatory intent
- Establishes and communicates policy to Plans by way of authorship of OPL specific content to the FEP Administrative Policy Manual (APM) and Benefits Policy Manual (BPM), which are published to Plans online via a Plan portal and as needed, via Special Memorandum.
- Responds to all Plan and vendor OPL inquiries including ones submitted via FEP Hub. Directs and executes activities for the internal Medicare Primary Denial Workgroup to include initiation of new central claims processing controls, in response to OPM and Office of Inspector General (OIG) audit findings, and management of the long-term effectiveness of those changes.
- Defines and fosters OPL data needs to avoid future findings in this and other OPL areas by working with the information technology data analytics team, on the availability and accessibility of critical claim data fields required for effective analysis and informatic purposes.
- Creates, implements, and maintains methodologies and processes designed to ensure long term program savings and compliance.
- Provides strategic direction on FEP policy as liaison to, and serves as a member of, the external and independent National Other Party Liability Group (NOPLG) Executive Committee.
- Section 111 Reporting Compliance-Reviews, approves, and manages analysis activities on Medicare Secondary Payer (MSP) federally mandated group health reporting for FEP membership, under the Section 111 Exchange, by the FEP Operation Center (FEPOC) and maintains effective business relationship with Section 111 governmental counterparts to address policy/reporting issues.
- OPL Product Lead-Provides direction to FEPOC staff on execution and administration of the COB Smart product data exchange activities with the Council for Affordable Quality Health Care (CAQH) and the FEPOC.
- Develops and maintains business relationships, in support of effective policy guidance development and the practical execution of that policy, with CAQH leadership and payer participants, federal agency partners on Medicare (HHS-CMS), Workers Compensation (DOL) and on reimbursement activities with IHS, DoD and VA.
- Relationship Management-Develops and maintains effective business relationships, in support of FEP OPL business policy interests and accurate payment, with external federal agencies (CMS, DOL, IHS, DoD, VA) staff, CAQH and internal groups/cross-functional teams.
- Works closely with the internal legal department to ensure compliance with applicable regulations.
- Identifies opportunities/needs and works with team-leads across the organization to establish strong relationships and influence decisions.
- Reporting & Escalation-Conducts OPL quarterly analysis including reporting to OPM on contract savings and trend under annual Service Charge activities and other business reporting.
- Escalates risks/issues with legal, in a timely manner, to FEP leadership on regulatory impacts.
Required Education, Certifications and Experience
- Bachelors Degree in business administration, or other related fields Political Science, Public Administration, Public Policy, or related field or equivalent work experience
- Minimum 8 years of health benefits policy development or provider reimbursement experience in areas including OPL and federal health programs
- Extensive knowledge of Health Care industry
- Possesses strong business project management skills
- Demonstrates the ability to manage and prioritize multiple projects concurrently
- Possesses effective organization, presentation, negotiation, and communications skills (oral and written)
- Demonstrates the ability to effectively and tactfully communicate relevant, and potentially difficult/sensitive information, to senior management in a timely manner
- Proven track record developing key business partnerships both internally and externally
- Demonstrates the ability to draw upon extensive knowledge and relationships to identify issues and develop appropriate policy positions
- Demonstrate strategic thinking and approach to problem solving
- Proven track record resolving and/or escalating issues, proposing alternatives and setting / managing expectations in a timely fashion
Preferred Education, Certifications and Experience
- Masters Degree
- Minimum 5 years of medical claims processing, claims auditing or data analysis experience
People Management - No