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Medicare Compliance Analyst

2 months ago

Southfield, Michigan, United States w3r Consulting Full time



SUMMARY:
The Healthcare Data Analyst role involves supporting Medicare Advantage PPO, HMO, and PDP plans in achieving compliance with CMS regulations concerning PBM oversight, CMS reporting, and benefit configuration and testing. Additional competencies may be necessary to fulfill the responsibilities of this position. The stated hourly rate is an estimate and does not represent the final negotiated compensation.

RESPONSIBILITIES/TASKS:
1.

Enhances and refines workflows and business processes to elevate customer service, reduce operational expenses, and enhance overall quality.

2. Collaborates with Customer Service to address inquiries and provides clear communication of responses.
3. Aids in CMS and other data audits conducted by CMS and internal audit teams.
4. Identifies and analyzes business challenges and formulates procedures for effective solutions.
5. Successfully leads projects to achieve desired outcomes.
6. Responsible for communicating project results within the organization.
7. Suggests and assists in the implementation of standardized policies and procedures.
8. Ensures ongoing communication, implementation, and monitoring of corporate compliance.
9. Engages in systems testing, develops procedures and controls, and offers recommendations for continuous improvement of the updated processes.
10. Supports personnel (both internal and external) by addressing questions, providing information, and facilitating training.
11. Cultivates and maintains effective working relationships with clients.
12. Participates in group or committee discussions.

Education:
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 defined by the Company's learning philosophy, is required.

EXPERIENCE:

  • 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-related issues.
  • Experience in timely responses to CMS inquiries regarding pharmacy claims.

SKILLS/KNOWLEDGE/ABILITIES (SKA)

REQUIRED:
1. Familiarity with pharmacy claim processing and Medicare guidelines related to Part D products.
2. Strong organizational skills and ability to prioritize; capable of managing multiple activities with varying timelines.
3. Willingness to learn and take on additional responsibilities as needed.
4. Experience with PBM systems and tools.
5. Ability to comprehend inquiries from external sources and provide timely and accurate responses.
6. Proven experience in operational analysis, data analysis, and problem resolution.
7. Strong analytical, organizational, planning, and problem-solving skills.
8. Understanding of the business, products, programs, corporate structure, and basic research methodologies.
9. Ability to plan, organize, direct, and manage projects effectively.
10. Excellent written and verbal communication skills.
11. Capacity to lead and contribute to process improvement initiatives.
12.

Ability to read and interpret documents such as data flows, process flows, technical diagrams, operating instructions, and procedure manuals. Proficient in writing routine reports and correspondence. Capable of presenting effectively to groups of clients or employees.

13. Ability to apply common sense to execute instructions provided in written, oral, or diagram form. Competent in addressing problems involving several concrete variables in standardized situations.
14. Adhere to corporate and departmental policies, practices, and procedures.