Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Medicare Operations Lead

Manager & Professional
190KR Requisition #
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Lead the effectiveness of EmblemHealth’s Medicare Product internal and external operations as a Medicare Subject Matter Expert.  Develop, monitor and assess project goals and objectives to manage new and or modified operational processes.  Evaluate the operational success of Medicare Product on an ongoing basis using a dashboard of key performance indicators.  Advance short- and long-term project solutions for operational issues and Product strategies.


Project Management
  • Independently manage the timely and effective implementation of projects related to new or existing  Medicare performance, including but not limited to changes in member benefits, inter/intra departmental corrective action plan development, implementation and assessment to achieve product performance; enhancements  to revenues and the member experience; enhancements to IT systems and operations; and other special projects as assigned.
  • Analyze regulatory and or delegate contractual materials as necessary to ensure timeliness and quality of program, including but not limited to developing project plans and ensuring development and dissemination of best program practices. 
  • Prepare Business Requirement Documents as needed.
  • Organize and chair meetings with affected departments, behavioral health vendors, community organizations to adhere to contractual deadlines, collaboratively addressing\resolving member issues. 
  • Conduct Medicare Product post implementation, on-going monitoring and assessments.
  • Design data sets, collect data, research issues, analyze and disseminate quantitative and qualitative reports that demonstrate the effectiveness of EmblemHealth’s Medicare Product.
  • Ensure the development and dissemination of best program practices with the Medicare arena at EmblemHealth. 
  • Effectively become a Medicare Subject Matter Expert to effectively lead the operations of the Medicare Product.
  • Inform all related inter and intra departments on needed communication and deliverables.  

SSP Subject Matter Expert (SME)
  • Interpret/obtain clarification of contract provisions, Medicare regulatory requirements and services.
  • Lead/participate in interdepartmental/intradepartmental in-service training sessions.
  • Participate in planning/problem resolution.
  • Lead efforts to track program efficiencies and product performance. 
  • Represent EmblemHealth in relevant stakeholder, planning, development and advocacy meetings and communicate/coordinate as necessary.
  • Assist in the development/update of member educational materials, as needed 

Regulatory Audits
  • Lead/participate in the preparations for annual regulatory onsite contract compliance reviews.
  • Assist in the resolution of various regulatory audits. 
  • Draft responses to member, community organization and regulatory agency correspondence.
  • Bachelor’s degree required
  • 5 – 8 years of related work experience required
  • Minimum of 3 - 5 years’ experience in health/Medicare or related field preferred
  • Experience in audit preparation and participation preferred
  • Minimum 3 years’ project management experience required
  • Excellent communications skills (verbal, written, presentation), and the ability to communicate effectively with all types and levels of audiences; and the ability to persuade and influence required
  • Detail orientation; analytic and problem solving skills required
  • Work experience in a Managed Care Plan and/or working knowledge of state sponsored health care programs preferred
  • Experienced in working with State/local government and community organizations preferred

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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