Operations Planning Specialist (PDP Oversight & Monitoring)

Health Care Service Corporation; Nashville (TN); On-site; USD 42,000 - 93,000; Full time

Job summary

Health Care Service Corporation seeks a detail‑driven analyst to oversee PDP Enrollment & Premium Billing operations with vendors and internal partners. You will monitor CMS requirements, track metrics, and report results to leadership, ensuring compliant processes and timely remediation.

This remote role requires 3–4 years in Medicare/environment and strong Excel/reporting skills. Collaboration with cross‑functional teams and proactive problem solving are essential to success.

Qualifications

• Bachelor's degree or equivalent experience.
• 3–4 years of Medicare or government program experience in eligibility, premium billing, or healthcare operations.
• Proficiency with Microsoft Word, Excel, Outlook, PowerPoint.
• Ability to work independently and in a matrixed environment.
• Strong analytical, problem-solving, and written/verbal communication skills.
• Ability to handle ambiguity and learn quickly.

Responsibilities

• Support daily oversight and monitoring of PDP Enrollment & Premium Billing operations with the vendor, internal and external partners.
• Interpret CMS requirements to ensure processes comply with CMS.
• Monitor operational metrics, critical volumes, and daily inventory to proactively identify potential issues.
• Review Service Level Agreement (SLA) on a monthly basis and work with vendor/matrix partners to address any issues impacting enrollment and billing operations.
• Manage weekly monitoring activities; pulling samples, tracking results and evidence of corrective action to support CPE audits, and prepare results reporting for leadership.
• Perform focused monitoring/audits post deployment of changes to operational processes.
• Participate in and actively support all internal, external, and CMS audit activities by quality reviewing universes, samples and all supporting documentation.
• Identify and articulate trends and issues found in monitoring and work with business partners and vendor for remediation and/or process improvements.
• Support additional duties and projects based on business needs such as AEP and 1/1 Readiness activities related to enrollment and billing.
• Support Annual review of vendor policy & procedures to ensure processes are up to date and current with CMS guidance and Company Business policies.

Skills

Medicare knowledge

Analytical skills

Communication skills

Team collaboration

Education

Bachelor's degree or equivalent experience

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft PowerPoint

Job description

At HCSC, our employees are the cornerstone of our business and the foundation to our success. We empower employees with curated development plans that foster growth and promote rewarding, fulfilling careers.

Join HCSC and be part of a purpose-driven company that will invest in your professional development.

BASIC FUNCTION

This position will be accountable to support oversight and monitoring of individual Prescription Drug Plan (PDP) Enrollment & Premium Billing operations, compliance with CMS (Centers for Medicare & Medicaid Services) requirements, mock audit support and CMS plan audits support. Will be responsible for oversight of Enrollment & Premium Billing operations to identify non-adherence to established processes as well as identify improvement opportunities, reporting results through ongoing audit spreadsheets, dashboards and scorecards. This role includes vendor oversight and collaboration as well as coordination with other internal partners and other lines of business for consistent processes across operations. NOTE: this is classified as a REMOTE opportunity and candidates must reside in and be authorized to work in a state where HCSC is approved to employ remote workers. Applicants residing in restricted states (i.e. AK, CA, HI, NY) are not eligible for employment consideration for this position.

Job Requirements

• Bachelor's Degree or equivalent experience.
• 3-4 years of relevant Medicare (Part D and/or Part C) or other government program experience in eligibility, premium billing or healthcare operations.
• Proficiency with Microsoft Word, Excel, Outlook, PowerPoint.
• Must be self-motivated and possess the competencies required to work in a fast-paced and heavily matrixed environment
• Ability to perform responsibilities independently as well as an effective team member
• Excellent conceptual and analytical skills with the ability to identify linkage between interfacing systems and processes, identify issues and manage/execute solutions to resolution.
• Strong problem solving skills and detail orientation.
• Ability to analyze situations and is comfortable dealing with ambiguity.
• Capacity to learn process and product information quickly and efficiently.
• Excellent organizational and written/verbal communication skills.

Preferred Qualifications

• Knowledge of advanced Excel, report writing, and analysis activities.
• Enrollment and eligibility experience and process improvement is a plus.
• Medicare Advantage or Part D experience.

~ KEY RESPONSIBILITIES ~

• Support daily oversight and monitoring of PDP Enrollment & Premium Billing operations with the vendor, internal and external partners. Includes BPO vendor, Pharmacy Claim vendor (Express Scripts), and internal HCSC Business and matrix partners.
• Perform ongoing review and interpretation of new and existing CMS requirements to ensure processes are compliant with CMS.
• Monitor operational metrics, critical volumes, and daily inventory to proactively identify potential issues.
• Review Service Level Agreement (SLA) on a monthly basis and work with vendor/matrix partners to address any issues impacting enrollment and billing operations
• Manage weekly monitoring activities; pulling samples, tracking results and evidence of corrective action to support CPE audits, and prepare results reporting for leadership.
• Perform focused monitoring/audits post deployment of changes to operational processes.
• Participate in and actively support all internal, external, and CMS audit activities by quality reviewing universes, samples and all supporting documentation.
• Identify and articulate trends and issues found in monitoring and work with business partners and vendor for remediation and/or process improvements.
• Support additional duties and projects based on business needs such as AEP and 1/1 Readiness activities related to enrollment and billing.
• Support Annual review of vendor policy & procedures to ensure processes are up to date and current with CMS guidance and Company Business policies.

Compensation: $41,700.00 - $92,800.00

Exact compensation may vary based on skills, experience, and location

HCSC Employment Statement

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

To learn more about available benefits, please click https://careers.hcsc.com/totalrewards