Director PACE Business Operations

Direct and oversee the day-to-day business operations of the PACE program, including insurance eligibility (Medicare/Medicaid), transportation, claims processing, and vendor contracts to ensure alignment with ministry goals

Oversee and direct claim processing operations to ensure timely and accurate payments according to vendor contracts and CMS guidelines

Oversee and directs enrollment and eligibility operations to ensure accurate membership and capitation

Ensure fleet of vehicles meets operational needs

Develop and maintains Standard Operating Procedures for all Medicare Part D Pharmacy operations through collaboration with pharmacy and PBM

Analyze key performance indicators (KPIs) to drive data-informed decisions, maintain adequate staffing levels that support operational needs, and to optimize organizational performance

Recruit and maintain a high-quality provider network of specialists and providers as required by PACE CMS regulations

Direct the negotiation, drafting, and execution of vendor contracts 

Oversee and directs timely reviews and monitoring of vendor compliance with contractual standards and with CMS regulations

Facilitate strong vendor relationships through frequent communication with vendors

Identify gaps in service delivery and coordinates process improvement with pharmacy and all vendor types

Financial Stewardship

Ensure adherence to all CMS, state, and federal regulations governing PACE operations. This requires coordination and collaboration with the Pace Medical and Administrative teams, Compliance Officer, Finance team, the PBM, and participation audits

Direct compilation of all required data for analysis and quality review prior to submission to CMS for Part D monthly, quarterly, and annual reporting, including but not limited to: Development of the Benefit Plan, Explanation of Benefits (EOB), Coordination of Benefits (COB), Prescription Drug Events (PDE), etc.

Monitor reporting submissions to regulatory agencies. Ensures submissions of various regulatory and/or financial reports and data as required (including HPMS) in coordination with Administrative Director, Financial Operations Manager, Compliance Officer, and others

Take a lead role in compliance audits and readiness activities, including preparation for CMS and other regulatory body reviews

Direct internal business operations related to the program’s provision of Part D medications

Serve as the co-chair of the Compliance Committee to ensure operational alignment with regulatory requirements of program operations oversight

Contribute to the Medicare Part D bid process in coordination with Milliman and the Financial Operations Manager. May serve as a contact for actuaries in bid-development. Operationally manages the Part D reserve model

Coordinate with legal, risk, and compliance teams to ensure that risk management strategies comply with CMS regulations and best practices Implement and monitor risk management strategies to mitigate operational vulnerabilities

Develop policies and procedures that meet compliance requirements

Develop and executes comprehensive operational strategies to support the organization’s mission, vision, and goals under the direction of the Administrative Director.

Collaborate with PACE Directors to identify and implement opportunities for process improvement, scalability, and efficiency across all departments

 Collaborate with PACE executive and PACE clinical leadership to align operational objectives with financial and participant-centered goals

Supply Chain & Resource Management 

Team Development and Leadership

Participant and Stakeholder Engagement