Randy joined CMS 17 years ago as an analyst working on Medicare eligibility and enrollment policy, followed by leading the Medicare Enrollment and Eligibility Division during the launch of the Medicare Part D benefit. Randy also served as the Deputy Director of the Medicare Enrollment and Appeals Group before taking his current role in the Offices of Hearings and Inquiries.
Prior to joining CMS, Randy worked for a private health insurance company in upstate New York for over 12 years in a variety of roles including management and oversight of that organization’s Medicare business operations.
Jim has an excellent depth of knowledge and experience across a wide array of CMS business areas, including Marketplace Appeals, Section 504 Accessibility for External Communications, the Medicare ombudsmen programs, casework, and beneficiary addresses, as well as Medicare Enrollment Operations, Plan Payment and the Retiree Drug Subsidy Program. He has been involved with the implementation of a number of CMS priorities including Medicare Part D and the Medicare Advantage portion of the Electronic Health Records initiative as well as portions of the Patient Protection and Affordable Care Act.
Before joining CMS in 2005, Jim was the Deputy Director of the Office of Governmental Affairs for the Maryland Department of Health and Mental Hygiene, as well as a legislative and regulations officer, and staff attorney, for the Maryland Board of Pharmacy.
OHI Functional Statement
- Serves as the CMS executive agent for developing and directing certain Exchange-based (Marketplace) health insurance eligibility appeals functions and processes in support of statues and regulations, particularly the Patient Protection and Affordable Care Act of 2010 and the Health Care and Education Reconciliation Act of 2010 (together, "the Affordable Care Act" or ACA).
- Assures regulatory and operational compliance conditions are known, assessed, addressed, assured and corrected where necessary. Coordinates with the Office of General Counsel (OGC) and Center for Consumer Information and Insurance Oversight as appropriate.
- Establishes and maintains appropriate mission and operational relationships with partners, stakeholders and significantly interested parties that are constructive to the fulfillment of eligibility appeals responsibilities.
- Establishes, promotes and supports governing bodies and processes to ensure numerous agencies, entities and components collaborate in areas relevant to appeals interests and deliberate in a fully informed manner.
- Develops and maintains program standards, strategies, plans, programs, and projects essential to meeting high priority, mission critical program objectives and ensure effective relationships with enterprise partners and stakeholders.
- Directs activities of subordinate groups in their fulfillment of assigned responsibilities associated with processing, adjudicating and communicating appeals determinations, dispositions, inquiry resolutions, administrative hearings officer rulings, board decisions and other outcomes.
- Performs senior executive functions including setting and monitoring performance and developmental goals, managing risk, assuring goal attainment, and reporting program conditions to agency leadership.
- Manages organizational operations and resources in an innovative, efficient and accountable manner.
- Supports the Medicare Beneficiary Ombudsman and Competitive Acquisition Ombudsman in order to provide assistance to individuals entitled to benefits under Title XVIII, resolve complaints and provide guidance to the Agency to identify and resolve issues. Assesses Medicare program policy and operations and the impact on beneficiaries in order to affect positive change in the manner in which we provide customer service to people with Medicare.
- Manages and provides oversight to the identification and correction of data discrepancies in Medicare enrollment, direct and third-party billing, Medicare Advantage, and Part D transaction exceptions. Screens complex casework for verification and coordinates disposition.
- Provides professional staff support to the Provider Reimbursement Review Board (PRRB) and the Medicare Geographic Classified Review Board (MGCRB).
- Conducts Medicare and Medicaid Hearings on behalf of the Secretary or the Administrator that are not within the jurisdiction of the Departmental Appeals Board, the Social Security Administration's Office of Hearings and Appeals, the PRRB, the MGCRB, or the States.
- Provides CMS-wide guidance and oversight that promotes and enforces compliance with Section 504 of the Rehabilitation Act of 1973, Title 29, United States Code for external communications and promotes the representation of individuals with disabilities through community outreach and other activities.
- Provides mechanisms for the provision of communications in alternate formats appropriate to the needs of the qualified external customer or individual with a disability.