Medicare Operations Analyst

Overview

The Medicare Operations Analyst is responsible for ensuring operational excellence acrossdelegated entities during implementation and post Go-Live implementation for Medicare DSNPprogram. In collaboration with the respective department, this role oversees implementation andpost-implementation day-to-day operations including enrollment, claims processing,utilization/case management (UM/CM), and call center performance. The Analyst will monitor,audit, and collaborate with delegated partners to ensure adherence to CMS regulations,organizational policies, and contractual requirements. Review daily/weekly/monthly operationalreports.

Responsibilities

▪ Validates file intake, effective dates, transaction codes (add/change/term), andretroactivity handling.▪ Validates compliance with CMS enrollment rules, including effective dates anddisenrollment procedures.▪ Monitors enrollment files and reconciliation processes to ensure timely and accuratemember onboarding.▪ Confirms vendor logic for ID cards, ANOCs/EOCs, welcome kits, PCP assignments.▪ Validates fee schedules, OON rules, bundling/unbundling edits, prior auth linkages.▪ Validates IVR menus, skills-based routing, disaster recovery, and call recordingretention.▪ Reviews scripts, FAQs, compliance call flows (no steering/misleading), language accessand interpreter processes.▪ Ensures delegated UM/CM programs meet regulatory standards.▪ Develops test plans covering unit, system, integration, regression, User AcceptanceTesting (UAT), and operational readiness (ORR) during implementation.▪ Manages log and prioritize defects; verifies fixes; manages exit criteria for each phaseduring implementation.▪ Serves as the primary liaison for delegated entities managing enrollment, claims,UM/CM, and call center operations. Oversees delegated claims processing for accuracy,timeliness, and adherence to CMS requirements.▪ Identifies and resolves systemic issues impacting claims adjudication and paymentintegrity.▪ Reviews UM reports and dashboards to identify trends, outliers, and potentialcompliance risks.▪ Monitors delegated call center performance reports for compliance with CMS callhandling standards, including timeliness and accuracy of information.

▪ Reviews member complaint logs and ensures resolution within required timeframes.▪ Stays current with CMS regulations, HPMS memos, and industry best practices.▪ Supports readiness for CMS audits and compliance reviews.▪ Conducts regular audits and monitoring activities to ensure compliance with CMSguidelines and organizational standards.▪ Reviews and validates reports from delegated partners for accuracy, timeliness, andcompleteness.▪ Maintains documentation of oversight activities and corrective action plans.

Qualifications

Education and Experience

Bachelor’s degree in healthcare administration, Business, or relatedfield (or equivalent experience). In lieu of a degree, a minimum ofeight (8) years of relevant health plan operations experience isrequired. Three (3) to five (5) years of experience in Medicare DSNPoperations. Strong knowledge of CMS regulations. Experience withauditing, compliance monitoring, and performance reporting.

Special Skills, Licenses and Certifications

Familiarity with NCQA standards. Experience working with delegatedvendors. Experience supporting CMS program audits and correctiveaction plans. Excellent communication, analytical, and problemsolving skills.

Performance Based Competencies

Ability to evaluate plan performance. Develop and execute strategicbusiness initiatives. Perform policy development and implementationin the areas of Medicare and Medi-Cal. Conduct compliance andregulatory-related research and analysis to support decision-makingand planning for major strategic initiatives. Communicate effectively,both verbally and in writing. Perform Project Management activities.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. Morethan 50% of work time is spent in front of a computer monitor. Whenrequired, ability to move, carry, or lift objects of varying size, weighingup to 35 lbs

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$106,667.05 - $138,667.16

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.