Medicare Operations Analyst

2 weeks ago

Southfield, Michigan, United States TekWissen LLC Full time
Job DescriptionOverview: TekWissen Group is a prominent workforce management provider operating across the USA and internationally. Our client is a leading health insurance organization offering a variety of health care coverage options, including individual and family plans, dental and vision coverage, and employer-sponsored plans.
Position: Health Care Analyst
Work Location: Southfield, MI
Contract Duration: 12 Months
Job Type: Contract
Work Type: Onsite
Department: Medicare Pharmacy Operations
Engagement Overview:
  • The Health Care Analyst role involves supporting Medicare Advantage PPO, HMO, and PDP plans in meeting CMS compliance standards related to PBM oversight, CMS reporting, and benefit configuration and testing.
  • Additional relevant skills may be necessary for this position. The stated hourly rate is a budget estimate and may not represent the final negotiated rate.
Key Responsibilities:
  • Enhance workflows and business processes to boost customer service, reduce operational expenses, and elevate overall quality.
  • Provide assistance to Customer Service by addressing inquiries and clearly communicating responses.
  • Support CMS and internal audit teams during data audits.
  • Identify and analyze business challenges, developing procedures for effective solutions.
  • Lead projects to achieve desired outcomes.
  • Communicate project results effectively within the organization.
  • Recommend and assist in the implementation of standard policies and procedures.
  • Ensure ongoing communication, implementation, and monitoring of corporate compliance.
  • Participate in systems testing, develop procedures and controls, and offer recommendations for continuous process improvement.
  • Assist both internal and external personnel by providing information and training.
  • Foster and maintain effective working relationships with customers.
  • Engage in group or committee discussions.
Education Requirements:
  • A Bachelor's degree in a relevant field is preferred.
  • A relevant combination of education and experience may be considered in lieu of a degree.
  • Continuous learning, as outlined by the Company's learning philosophy, is essential.
Experience Requirements:
  • A minimum of four (4) years of experience in a related field is required, preferably in health plans or PBM.
  • Proficiency in Microsoft Office applications, including Excel, Word, and Outlook.
  • Strong data analysis and problem resolution skills.
  • Experience with spreadsheets and/or databases.
  • Experience in resolving eligibility and pharmacy claims issues.
  • Experience in timely responses to CMS inquiries regarding pharmacy claims.
Required Skills/Knowledge/Abilities:
  • Understanding of pharmacy claim processing and Medicare guidance related to Part D products.
  • Strong organizational skills with the ability to prioritize and manage multiple activities with varying timelines.
  • Willingness to learn and take on additional responsibilities as needed.
  • Familiarity with PBM systems and tools.
  • Ability to comprehend inquiries from external sources and provide timely, accurate responses.
  • Proven experience in operational analysis, data analysis, and problem resolution.
  • Strong analytical, organizational, planning, and problem-solving skills.
  • Understanding of the business, products, programs, corporate structure, and basic research methodologies.
  • Ability to plan, organize, direct, and control projects effectively.
  • Excellent written and verbal communication skills.
  • Capability to lead and contribute to process improvement initiatives.
  • Ability to interpret various documents, including data flows, process flows, and procedure manuals.
  • Ability to compose routine reports and correspondence.
  • Effective public speaking skills before groups of customers or employees.
  • Ability to apply common sense in executing instructions provided in written, oral, or diagram form.
  • Ability to address problems involving multiple concrete variables in standardized situations.
  • Adhere to corporate and departmental policies, practices, and procedures.
TekWissen Group is an equal opportunity employer committed to supporting workforce diversity.

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