Medicare Compliance Analyst

1 week ago

Southfield, Michigan, United States w3r Consulting Full time



SUMMARY:
The Healthcare Data Analyst role focuses on supporting Medicare Advantage PPO, HMO, and PDP plans in fulfilling CMS compliance obligations related to PBM oversight, CMS reporting, and benefit configuration and testing. Additional relevant skills may be necessary to effectively execute this position. The maximum hourly compensation indicated is a budgetary estimate and does not represent the final negotiated rate.

RESPONSIBILITIES/TASKS:
1.

Enhances and optimizes workflows and business processes within designated areas to elevate customer service, reduce operational expenses, and enhance overall quality.

2. Provides assistance to Customer Service with inquiries and communicates responses clearly.
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. Effectively leads projects to achieve desired outcomes.
6. Responsible for corporate communication regarding project outcomes.
7. Proposes 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/controls, and offers recommendations for continuous improvement of updated processes.
10. Supports personnel (both internal and external) by addressing inquiries, providing information, and delivering 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 essential.

EXPERIENCE:

  • 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, including spreadsheet and/or database expertise.
  • Experience in resolving eligibility and pharmacy claims-related issues.
  • Familiarity with responding to CMS inquiries regarding pharmacy claims in a timely manner.

SKILLS/KNOWLEDGE/ABILITIES (SKA)

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

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

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

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