Medicare Compliance Analyst

1 week ago

Southfield, Michigan, United States OpTech Full time
Job Title: Health Care Analyst

Why work at OpTech?
OpTech is a woman-owned organization that values your contributions, fosters your development, and consistently supports you. At OpTech, you will receive health and dental benefits from your first day of employment, along with training opportunities, flexible and remote work options, career advancement, a 401K plan, and competitive compensation. To explore our full range of job openings, please visit our website.

POSITION OVERVIEW:

ROLE SUMMARY:
  • The Health Care Analyst role is tasked with aiding Medicare Advantage PPO, HMO, and PDP plans in fulfilling CMS compliance obligations related to PBM oversight, CMS reporting, and benefit configuration and testing.
KEY RESPONSIBILITIES:
  • Enhances and refines workflows and business processes to elevate customer service, reduce operational expenses, and enhance overall quality.
  • Supports Customer Service by addressing inquiries and effectively communicating responses.
  • Aids in CMS and other data audits performed by CMS and internal audit teams.
  • Identifies and analyzes business challenges and formulates procedures for resolution.
  • Successfully leads projects to achieve desired outcomes.
  • Responsible for corporate communication regarding project outcomes.
  • Proposes and assists in the implementation of standard policies and procedures.
  • Ensures ongoing communication, implementation, and monitoring of corporate compliance.
  • Engages in systems testing, develops procedures and controls, and offers recommendations for continuous process improvement.
  • Assists both internal and external personnel by providing information and training.
  • Cultivates and maintains effective working relationships with clients.
  • Participates in group discussions or committee meetings.
REQUIRED QUALIFICATIONS:

EXPERIENCE:
  • A minimum of four (4) years of experience in a related field is essential (preferably in health plans or PBM).
  • Proficiency in Microsoft Office applications, including Excel, Word, and Outlook.
  • Must possess data analysis and problem-solving capabilities
    • Experience with spreadsheets and/or databases.
  • Familiarity with resolving eligibility and pharmacy claims issues.
  • Experience in responding to CMS inquiries regarding pharmacy claims in a timely manner.
  • Additional related skills may be necessary for this role.
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
  • Understanding of pharmacy claim processing and Medicare guidelines related to Part D products.
  • Strong organizational skills and the ability to prioritize; capable of managing multiple tasks with varying deadlines.
  • Willingness to learn and take on additional responsibilities as needed.
  • Experience with PBM systems and tools.
  • Ability to comprehend inquiries from external sources and provide timely and accurate responses.
  • Analyst experience is required, with proven expertise in operational analysis, data analysis, and problem resolution activities.
  • Strong analytical, organizational, planning, and problem-solving skills.
  • Knowledge of the business, products, programs, corporate structure, and basic research principles/methodologies.
  • Capability to plan, organize, direct, and manage projects.
  • Excellent written and verbal communication skills.
  • Ability to lead and contribute to process improvement initiatives.
  • Proficient in reading and interpreting documents such as data flows, process flows, technical diagrams, and procedure manuals. Capable of writing routine reports and correspondence.
  • Ability to effectively present information to groups of clients or employees.
  • Ability to apply common sense understanding to execute instructions provided in written, oral, or diagram form.
  • Ability to handle problems involving several concrete variables in standardized situations.
  • Adhere to corporate and departmental policies, practices, and procedures.
Education:
  • A Bachelor's degree in a related field is preferred.
  • A relevant combination of education and experience may be considered in lieu of a degree.
  • Continuous learning, as defined by the Company's learning philosophy, is mandatory.
OpTech is an equal opportunity employer committed to fostering a diverse environment. All qualified applicants will be considered for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, parental status, disability, age, veteran status, or other characteristics defined by federal, state, or local laws.

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