[Remote] Operational Leader - CMS WISeR Program Clinical Operation

Note: The job is a remote job and is open to candidates in USA. Genzeon is seeking an experienced Operational Leader to oversee clinical operations for the CMS Wasteful and Inappropriate Service Reduction (WISeR) Model implementation in New Jersey. This role involves managing all operational aspects of the program, ensuring compliance with CMS requirements, and developing operational protocols for prior authorization processes. Responsibilities • Lead day-to-day operations of the WISeR program clinical workflows in New Jersey • Ensure compliance with all CMS requirements and model specifications • Develop and implement operational protocols for prior authorization review processes • Manage vendor partnerships for Business Process Outsourcing (BPO), mail room operations, and print services • Oversee third-party vendor performance and service level agreements • Coordinate logistics for document processing, mail handling, and printing requirements Skills • Minimum 7 years of healthcare operations management experience • 3+ years of experience with Medicare programs, prior authorization, or utilization management • Strong understanding of Medicare fee-for-service operations and regulations • Experience with prior authorization systems and clinical decision support tools • Proficiency in healthcare data analysis and reporting systems • Knowledge of fraud, waste, and abuse detection methodologies • Familiarity with electronic health records and healthcare technology platforms • Experience with automation technologies, AI/ML platforms, and process optimization tools • Proven track record of leading cross-functional teams in healthcare settings • Experience managing complex operational initiatives with multiple stakeholders • Strong project management skills with ability to meet strict deadlines • Change management experience, particularly in implementing new clinical processes • Deep understanding of Medicare regulations and compliance requirements • Knowledge of CMS Innovation Center models and demonstration programs • Familiarity with healthcare quality measures and reporting requirements • Understanding of New Jersey healthcare regulations and market dynamics • Previous experience with CMS demonstration models or innovation programs preferred • Experience with the specific services covered by WISeR (skin substitutes, electrical stimulators, orthoses) • Background in clinical operations for durable medical equipment or specialty services • Previous participation in CMS alternative payment models or demonstration programs • Professional certification in healthcare management (FACHE, CHAA, or similar) • Experience with artificial intelligence, machine learning, or robotic process automation in healthcare • Background in digital transformation and automation implementation • Knowledge of automated decision-making systems and clinical algorithms Education Requirements • Bachelor's degree required; Master's degree in Healthcare Administration, Business Administration, or related field preferred • Master's degree in Healthcare Administration, Business Administration, or related field preferred Company Overview • Genzeon is an AI and automation company with deep engineering and data expertise, dedicated to serving the healthcare industry. It was founded in 2012, and is headquartered in Exton, Pennsylvania, USA, with a workforce of 501-1000 employees. Its website is Apply tot his job