The Healthcare Analyst position is responsible for assisting Medicare Advantage PPO, HMO and PDP plans meet CMS compliance requirements for PBM oversight, CMS reporting, review member eligibility and reporting, benefit set up and testing. Other related skills may be required to perform this job. The maximum hourly rate reflects budget estimates only and does not reflect the final negotiated rate.
RESPONSIBILITIES/TASKS:
1. Develops and improves work flows and business processes within area(s) to improve customer service, decrease operational costs, and improve overall quality.
2. Assists Customer Service with questions and clearly communicates responses to inquiries.
3. Assist in CMS and other data audits conducted by CMS and internal audit teams
4. Identifies and/or analyzes business problems and devise procedures for solutions to the problems.
5. Effectively leads projects in order to produce desired results.
6. Responsible for corporate communication of project results.
7. Recommends and assists with implementing standard policies and procedures.
8. Assures that corporate compliance is communicated, implemented, and monitored on an ongoing basis.
9. Participates in systems testing, develops procedures/controls, and provides recommendations for the ongoing improvement of the updated process.
10. Assists personnel (both internal and external) by answering questions, supplying information, and training.
11. Develops and maintains an effective working relationship with customers.
12. Participates in group or committee discussions.
Education:
Bachelor’s degree in a related field is preferred. Relevant combination of education and experience may be considered in lieu of degree. Continuous learning, as defined by the Company’s learning philosophy, is required.
EXPERIENCE:
• Four (4) years’ experience in a related field is required (prefer health plan or PBM).
• Experience with Microsoft Office applications including Excel, Word and Outlook.
• Must have data analysis, and problem resolution skills. Spreadsheet and/or Database skills.
• Experience resolving eligibility and pharmacy claims related issues.
• Experience with responding to CMS requests regarding pharmacy claims timely.
