Mgr, Medicare & Medicaid Job in Pennington, NJ at Horizon Blue Cross Blue Shield of New Jersey

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Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The Manager, Medicare and Medicaid Risk Adjustment is responsible to act as the lead for multiple data projects and tasks working directly with the Director, Risk Adjustment Revenue. This position will be actively involved in managing the company’s Medicare and Medicaid risk adjustment revenue management and analysis. This position will work interdepartmentally as well as with outside vendors, such as, but not limited to, Inovalon, Cognizant, Cognisight, Apixio, Change Healthcare, Pharmacy Benefit Administrator (PBA), Membership Systems, etc., in matters related to the membership, revenue, risk adjustment accuracy, and data submission completeness & accuracy. Lead an analytics-focused team and manage a coordinated, cross-functional and integrated process across the organization with partners in Service, Informatics, HCM&T, and IT to implement the programs and streamline and leverage activities.

  • Manage the existing Medicare risk adjustment programs, ensuring risk score accuracy capabilities, timely and accurate data submissions, financial impact and related functions. Responsible for managing the Medicare Risk Adjustment Processing System (RAPS) and Encounter Data Processing (EDPS) Submission process and reconciliation of submissions against claims data. Coordinate the work of government audit on risk adjustment data (RADV Audit). Assist in implementation and management of Risk Adjustment related vendor activities.
  • Oversee DSNP vendor relationships, establishing clear performance goals and expectations. Coordinate the operations for vendors in developing data extracts for accurate and timely RAPS/EDPS submissions as it relates to chart review and in-home assessments. Track vendor progress in meeting deadlines, reporting accurate and complete data.
  • Establish appropriate receivable balances and the application of monthly payment remittances from the Centers for Medicare and Medicaid Services (CMS) and New Jersey State Department of Human Services Division of Medical Assistance and Health Services (DMAHS).
  • Manages the DSNP NJ State/CMS reconciliation of preparation and distribution of monthly premium and enrollment derived from the Monthly Membership Report (MRR) and Remittance Advice (RA) respectively.
  • Prepare and analyze financial data and reports and for maintenance and reconciliation of receivable balances and accounts. Implement and monitor basic control processes, communications improvements, and analysis.
  • Oversee Medicaid Pharmacy Benefit Administrator (PBA) ensuring timely and accurate Encounters submissions & reconciliation aligning with the TR65 certification. Coordinate cross-functional meetings with various functional areas to meet overall stakeholder expectations and plan’s objectives.
  • Manage data assurance and reconciliation of Medicare Prescription Drug Event (PDE) data interdepartmentally.
  • Responsible for duties including training, development, communication and implementation of office audit standards, policies and procedures, reviewing monitoring, establishing tasks, setting goals and evaluating of employee work performance, reviewing operational programs, establishing work priorities, and researching technical and procedural issues related, but not limited to the actions that could potentially affect the member premium. Work in partnership with customers, vendors, and other key stakeholders to deliver the service and products required. Create/revise policies and procedures in accordance with the State and federal requirements and maintain compliance.
  • Manage, develop and train four – six staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.


  • Bachelor degree preferred from an accredited college or equivalent work experience
  • Requires a minimum of five to eight years of experience in Accounting, Revenue and/or Healthcare Accounts Receivable Management, preferably for a payer organization
  • Requires premium and/or healthcare receivable management experience (claims processing experience is preferred).
  • Requires experience processing and analyzing large data files including directing the development of queries and reports to support the management of accounts receivable balances.
  • Experience in the Medicare and/or Medicaid Managed Care industry is preferred.


  • Requires working knowledge of personal computers and supporting windows based environment including MS Access, Excel, and Word.-Requires knowledge of claims processing.
  • Prefers knowledge of industry standard claims coding.
  • Requires knowledge of provider contracting.
  • Prefers knowledge of claim system configurations.
  • Prefers project management skills.
  • Knowledge of CMS Risk Adjustment Process (RAPS), State and Federal Encounters-Reporting, Part D, Premium Billing, Membership Reconciliation, CMS and State of NJ Revenue Cycle desired.

Skills and Abilities:

  • Requires analytical and problem solving skills.
  • Requires strong oral and written communication skills.
  • Requires the ability to adapt to change and meet deliverables in a fast paced, dynamic environment.
  • Requires the ability to research and resolve problems through interaction with companywide personnel.
  • Requires the ability to organize and prioritize work assignments.
  • Requires effective verbal and written communication skills and demonstrate the ability to work well within team.-Requires the ability to work independently and coordinate projects.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.