About Ramona Health:
We're building a new kind of Medicare Advantage plan designed from the ground up to actually improve senior health outcomes, not just manage sickness. We're integrating a proprietary AI coach with a network of high-touch Direct Primary Care (DPC) partners to create a proactive, personalized member experience focused on reversing chronic disease trends and reducing downstream costs. We are early-stage, ambitious, and aiming to launch our first MA plan in CY 2027. This is not for the faint of heart.
The Challenge & Opportunity:
Building any MA plan is exceptionally hard. Getting the initial regulatory approvals (CMS, State DOI) and building the compliant operational plumbing before you even enroll a single member is the first great filter. It requires deep knowledge, obsessive attention to detail, and the ability to navigate bureaucratic labyrinths under startup pressure. This role is about successfully overcoming that filter. We need someone to architect and implement the core MA infrastructure, ensuring we are fully compliant and ready to operate by launch.
Responsibilities
Your core mission over the next 18-24 months is to successfully guide Ramona Health through the complex process of CMS application, state licensure, network build-out, and operational readiness to launch a compliant and financially viable Medicare Advantage plan by CY 2027. This means:
- Lead the Path to Approval (Job #1): Own the entire CMS MA application lifecycle (NOIA, Application, readiness reviews, audits). Your primary objective is getting us successfully through the regulatory gates on time. You are the point person ensuring every 'i' is dotted and 't' is crossed for CMS and state regulators.
- Architect the MA Operations Foundation: Design, select vendors/partners for, and implement the MVP of our core MA plan operations: enrollment/billing processes, initial claims adjudication strategy (likely partnering heavily), member services workflow design (with AI integration points), basic utilization management framework (w/ CMO), initial Star Ratings tracking/strategy, risk adjustment operations planning, and potentially Part D strategy input. Focus on compliance, scalability, and what's essential for launch.
- Build the Compliance Program: Establish our MA compliance program from scratch. Be the internal authority on CMS and relevant state regulations. Ensure all operational designs and company activities meet stringent requirements.
- Ensure Network Compliance & Operational Integration: Partner closely with the CEO & CMO as they develop the DPC/value-aligned provider network strategy. Your critical role is to ensure the network structure, provider types, geographic coverage, and contracting terms meet all CMS network adequacy requirements and can be supported operationally. You are the compliance and operational reality check for the network build.
- Shape Strategy with MA Expertise: Provide the essential MA operational and regulatory grounding for product, tech, and fundraising efforts. Your understanding of MA economics (MLR impacts of operational choices, bid assumptions, admin costs) is crucial. Be prepared to rigorously challenge assumptions based on operational realities.
- Found the Ops/Compliance Team: Eventually, hire and manage the initial, lean MA operations and compliance staff, but expect to be doing much of the hands-on work yourself initially.
Requirements
Who We Need (The Non-Negotiables):
- Proven MA Launch Experience: You must have direct, hands-on experience successfully navigating the CMS MA application and approval process for a new plan launch or a significant Service Area Expansion. You know the detailed steps, the potential pitfalls, and how to work with regulators.
- Deep MA Operational Expertise: You understand the core mechanics of MA plan operations (claims process flows, enrollment/disenrollment, member communications, appeals & grievances, vendor oversight, basic UM concepts).
- Regulatory & Payment Systems Authority: Fluent in CMS regulations (Parts C & D), state insurance regulations relevant to MA plans, Risk Adjustment processes, and the Star Ratings program mechanics. You understand how these directly impact operations and finance.
- Startup Mentality: Thrive in ambiguity, prioritize ruthlessly, make decisions with incomplete data, resourceful, hands-on. You are comfortable building processes and structure where none exist. You understand the urgency of a startup timeline.
- Effective Collaborator: Can work closely and communicate clearly with clinical (CMO) and tech/product (CEO) leads, translating complex insurance requirements into understandable terms.
- Bonus Points (Nice-to-Haves): Experience launching or operating SNPs (especially C-SNPs), Experience integrating DPC or similar value-based primary care models within MA operations, Previous MA or value-based care startup experience, Experience implementing technology/automation in core insurance operations (e.g., claims, enrollment systems), Experience directly managing CMS audits.
What We Offer:
- High Impact & Equity: This is a ground-floor opportunity with significant ownership in what we build, vesting over time and with potential upside tied to key company milestones (like successful plan launch).
- Build From Scratch: The chance to design and implement an MA plan the right way, without legacy baggage.
- Mission-Driven Team: Work directly with a CEO and CMO laser-focused on improving health outcomes.
- The Startup Reality: Intense pace, high stakes, ambiguity, and the potential for massive reward.
- Competitive Salary (but the real upside is the equity).