Medicare Operations Analyst The Medicare Operations Analyst is responsible for ensuring operational excellence across delegated entities during implementation and post Go-Live implementation for Medicare DSNP program. In collaboration with the respective department, this role oversees implementation and post-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 operational reports. Validates file intake, effective dates, transaction codes (add/change/term), and retroactivity handling. Validates compliance with CMS enrollment rules, including effective dates and disenrollment procedures. Monitors enrollment files and reconciliation processes to ensure timely and accurate member 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 recording retention. Reviews scripts, FAQs, compliance call flows (no steering/misleading), language access and interpreter processes. Ensures delegated UM/CM programs meet regulatory standards. Develops test plans covering unit, system, integration, regression, User Acceptance Testing (UAT), and operational readiness (ORR) during implementation. Manages log and prioritize defects; verifies fixes; manages exit criteria for each phase during 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 payment integrity. Reviews UM reports and dashboards to identify trends, outliers, and potential compliance risks. Monitors delegated call center performance reports for compliance with CMS call handling 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 CMS guidelines and organizational standards. Reviews and validates reports from delegated partners for accuracy, timeliness, and completeness. Maintains documentation of oversight activities and corrective action plans. Bachelor's degree in healthcare administration, Business, or related field (or equivalent experience). In lieu of a degree, a minimum of eight (8) years of relevant health plan operations experience is required. Three (3) to five (5) years of experience in Medicare DSNP operations. Strong knowledge of CMS regulations. Experience with auditing, compliance monitoring, and performance reporting. Familiarity with NCQA standards. Experience working with delegated vendors. Experience supporting CMS program audits and corrective action plans. Excellent communication, analytical, and problem-solving skills. Ability to evaluate plan performance. Develop and execute strategic business initiatives. Perform policy development and implementation in the areas of Medicare and Medi-Cal. Conduct compliance and regulatory-related research and analysis to support decision-making and planning for major strategic initiatives. Communicate effectively, both verbally and in writing. Perform Project Management activities. Ability to use a computer keyboard and other business machines. More than 50% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up 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 - $138,667.16IMPORTANT DISCLAIMER NOTICEThe 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.
