medicaid product manager

Speridian Technologies

<div><h2 class="jobSectionHeader">Job Title: Principal Product Manager Claims and Encounters</h2><h2 class="jobSectionHeader">
Location: Remote (Working hours are Monday-Friday PST) 
Division: Medical Enterprise System Modernization Division (MESMD), Behavioral Health Transformation Project (BHT) 
Department: California Department of Health Care Services (DHCS)</h2><h2 class="jobSectionHeader">
Must work on shore in the US. We cannot sponsor or transfer an H1B Visa for this role.
</h2>About the Behavioral Health Transformation (BHT) Initiative 
California&rsquo;s behavioral health system is undergoing one of the most significant transformations in its history. Driven by new legislation&mdash;including the Behavioral Health Services Act and related reforms&mdash;DHCS is working to modernize how behavioral health services are delivered, tracked, and improved across the state. 
The BHT initiative is a multi-year effort to re-architect the way DHCS partners with counties and providers to deliver care, measure outcomes, and produce transparency, and accountability. This work requires a new generation of digital tools, data infrastructure, and service delivery models. At its core, BHT is about making real changes in the lives of Californians&mdash;ensuring every dollar spent can be tied to improved access, quality, and health outcomes. 
 
We are seeking a strong, multidisciplinary, Principal Product Manager to drive the modernization of our claims and encounter capabilities supporting Behavioral Health Transformation (BHT). 
While DHCS receives claims and encounter submissions today, the systems are fragmented and lack transparency for counties, providers, and managed care plans. We are building user-facing operational software that enables submitting entities to directly manage submission quality, reconciliation status, and reporting accuracy &mdash; and to be accountable for the integrity of their data. 
This role requires deep, hands-on experience owning Medicaid claims and encounter systems. The ideal candidate understands adjudication workflows, CMS reporting requirements, healthcare interoperability standards, and how operational systems drive accountability. 
Statement for Speridian Technology
Speridian Technology is an Equal Opportunity Employer. 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 characteristic protected by law. Reasonable accommodations are available for qualified individuals with disabilities during the application process. 
This is a senior individual contributor role operating and owning outcomes at the intersection of policy, operations, data standards, compliance, and engineering. 
 
What You&rsquo;ll Do<ul><li>
Translate the strategic requirements for BHT operational systems into an executable roadmap aligned to statutory deadlines.</li><li>
Own roadmap prioritization, epics, and user stories and ensure adherence to all technical delivery standards.</li><li>
Work directly with operations and data policy teams to transform state and federal financial and accountability reporting obligations into clear, implementable product requirements.</li><li>
Own the modernization and user experience of external-facing claims and encounters management software enabling submission, validation, reconciliation, transparency, accountability and compliance.</li><li>
Design user workflows that improve data quality at the source and give counties, providers, managed care plans, and DHCS visibility into submission status, data quality, state and federal compliance.</li><li>
Coordinate and drive the development of enterprise business process maps, data models, and technical architecture with policy, data, and engineering partners.</li><li>
Ensure claims and encounter systems integrate seamlessly with Medical Enterprise Systems.</li><li>
Define measurable outcomes tied to compliance, timeliness, reconciliation accuracy, and operational performance</li></ul> 
Required Experience 
Candidates must demonstrate:<ul><li>
10+ years of product management experience in healthcare technology</li><li>
Direct ownership of Medicaid or government healthcare claims and/or encounter systems</li><li>
Deep understanding of:</li><li>
Claims adjudication workflows</li><li>
Managed care encounter reporting</li><li>
CMS Medicaid reporting requirements</li><li>
CPT/HCPCS/ICD coding structures</li><li>
Substantial experience with healthcare data standards, including:</li><li>
USCDI</li><li>
HL7 / FHIR APIs</li><li>
Standard code sets and validation frameworks</li><li>
Experience translating regulatory and reporting requirements into system functionality</li><li>
Experience operating within California state reporting environments strongly preferred</li></ul>
Strongly Preferred<ul><li>
Experience modernizing or consolidating fragmented claims or encounter systems</li><li>
Experience building submission engines, validation services, or transaction gateways</li><li>
Familiarity with MITA and Medicaid Enterprise modernization</li><li>
Experience enabling user-facing operational tools that improve data quality and compliance</li><li>
Experience working in complex public-sector or managed care environments</li></ul> 
What Success Looks Like<ul><li>
Submitting entities have clear visibility into claims and encounter status and data quality</li><li>
Validation and reconciliation workflows are transparent and standardized</li><li>
Data quality improves at the point of submission rather than through downstream correction</li><li>
Claims and encounter capabilities integrate cleanly with other DHCS operational systems</li><li>
Operational accountability across delivery systems measurably increases</li></ul> 
Why This Role Matters 
Claims and encounter systems are foundational to Medi-Cal oversight, reporting, and payment integrity. Modernizing these capabilities enables transparency, improves data quality at the source, and strengthens accountability across California&rsquo;s behavioral health delivery system. 

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Principal Product Manager, Claims and Encounters

Humana

<div><h1 class="jobSectionHeader">Become a part of our caring community and help us put health first 
</h1>
The new COE Product and Distribution Portfolio Principal will be responsible for advancing the integrated Dual Eligible Special Needs Plans (D-SNPs) approach to benefit design across VABs, Mandatory Supplemental Benefits and Covered Services. They will be responsible from design to delivery of fully developed products that are ready for customer use. This individual will work with Medicaid Market Leaders to ensure that benefit design meets each State priorities.
The COE Product and Distribution Portfolio Principal will lead strategic benefit planning meetings with DSNP Medicaid markets. They will be responsible for identifying product gaps, recommending product changes, schedule changes, cost adjustments, or resource additions, and overseeing the implementation of changes to products. Decisions are typically related to the implementation of new/updated products or large-scale projects for the function and supporting technical/operational procedures and processes, and implement strategic plans, drives goals and objectives, and improves performance. The individual will represent DSNP during the annual planning and bid cycle strategy. Ensuring all products can be implemented based on current operations. While communicating impacts to up and downstream partners to include corporate finance, actuarial, member and provider services as well as growth and strategy teams. Ultimately will be subject matter expert for all DSNP Medicaid markets; address questions including but not limited to regulations, feasibility of new benefit designs, sales questions and general product inquiries.
Product Innovation/Design:<ul><li>
Partners with cross-functional teams define, refine, and launch products that meet DNSP market demands and align with organizational goals.</li><li>
Advances technology strategy for integrated D-SNPs for associates, brokers and members</li></ul>
Product Management:<ul><li>
Directly accountable for the end-to-end development of DSNP Medicaid State Plans</li><li>
Lead the strategy and planning of new and existing benefits, creating a plan design that meets the needs of our members.</li><li>
Supports development of educational materials for integrated D-SNPs to members and brokers.</li><li>
Work to optimize distribution education awareness and marketing efforts for int D SNP product line</li><li>
Implementation and management of launched products and services.</li></ul>
Product Marketing/Strategic Oversight:<ul><li>
Monitors product performance, identify trends, and recommend strategic enhancements to optimize outcomes.</li><li>
Develops member experience and segmentation strategy for Integrated D-SNP members.</li><li>
Works to understand the member journey of an Int D SNP member and work across enterprise partners to develop ideal &lsquo;product&rsquo; experience</li></ul>
Navigating Ambiguity:<ul><li>
Demonstrates a proactive, problem-solving approach, effectively working in the &ldquo;gray&rdquo; to address challenges and drive clarity in complex situations.</li></ul>
Stakeholder Collaboration:<ul><li>
Acts as a key liaison with internal and external stakeholders, ensuring alignment on product goals, timelines, and success metrics.</li><li>
A liaison to Enterprise Growth AND MarketPOINT team for the Integrated D-SNP Product line. Work to define unique personas and care needs of Int D-SNP members to align optimal benefit packages and experiences across the Medicare and Medicaid Product line</li></ul><h1 class="jobSectionHeader"> 
Use your skills to make an impact 

</h1>Required Qualifications<ul><li>
Bachelor's degree or 6+ years Product/Distribution leadership experience</li><li>
5+ years of D-SNP and/or Medicaid experience; ideally with direct accountability in the Medicare bid and or Medicaid/Medicare Product and innovation teams</li><li>
2-5 years of product design, management and implementation experience</li><li>
Demonstrated track record of ability to tell the story, influence leaders and drive improvement activity in a matrixed organization</li><li>
Strong executive presence</li><li>
Comprehensive knowledge of all Microsoft Office applications, including Word, Excel and PowerPoint</li></ul>
Preferred Qualifications<ul><li>
2 yrs Medicare bid process</li></ul>
Additional Information
This position is open to working remote with a preference in KY, FL, IL, WI, IN, VA and/or MI
Work at Home Guidance
To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Interview Format
As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. 

$150,000 - $206,300 per year 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, &ldquo;Humana&rdquo;) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.<h1 class="jobSectionHeader"> 
About us 
</h1>
Humana Inc. (NYSE: HUM) is committed to putting health first &ndash; for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health &ndash; delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large. 
 
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.</div>

Medicaid Product and Distribution Leader

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Principal Product Manager, Claims and Encounters

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