A bachelor's degree in healthcare administration, business, or a related field, or equivalent experience; alternatively, a minimum of eight years of relevant health plan operations experience is required in lieu of a degree.
Three to five 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.
Ability to evaluate plan performance.
Ability to develop and execute strategic business initiatives.
Ability to perform policy development and implementation in Medicare and Medi-Cal.
Ability to conduct compliance and regulatory-related research and analysis to support decision-making and planning for major strategic initiatives.
Ability to perform project management activities.
Ability to use a computer keyboard and other business machines.
Ability to move, carry, or lift objects weighing up to 35 pounds when required.
Responsibilities
Ensure operational excellence across delegated entities during implementation and post-go-live operations for the Medicare DSNP program.
Oversee implementation and post-implementation day-to-day operations, including enrollment, claims processing, utilization and case management, and call center performance.
Monitor, audit, and collaborate with delegated partners to ensure adherence to CMS regulations, organizational policies, and contractual requirements.
Review daily, weekly, and monthly operational reports.
Validate file intake, effective dates, transaction codes, and retroactivity handling.
Validate compliance with CMS enrollment rules, including effective dates and disenrollment procedures.
Monitor enrollment files and reconciliation processes to ensure timely and accurate member onboarding.
Confirm vendor logic for ID cards, ANOCs/EOCs, welcome kits, and primary care provider assignments.
Validate fee schedules, out-of-network rules, bundling and unbundling edits, and prior authorization linkages.
Review scripts, frequently asked questions, compliance call flows, language access, and interpreter processes.
Ensure delegated utilization and case management programs meet regulatory standards.
Develop test plans covering unit, system, integration, regression, user acceptance testing, and operational readiness during implementation.
Manage and prioritize defect logs, verify fixes, and manage exit criteria for each implementation phase.
Serve as the primary liaison for delegated entities managing enrollment, claims, utilization and case management, and call center operations.
Oversee delegated claims processing for accuracy, timeliness, and adherence to CMS requirements.
Identify and resolve systemic issues affecting claims adjudication and payment integrity.
Review utilization management reports and dashboards to identify trends, outliers, and potential compliance risks.
Monitor delegated call center performance reports for compliance with CMS call-handling standards, including timeliness and information accuracy.
Review member complaint logs and ensure resolution within required timeframes.
Stay current with CMS regulations, HPMS memos, and industry best practices.
Support readiness for CMS audits and compliance reviews.
Conduct regular audits and monitoring activities to ensure compliance with CMS guidelines and organizational standards.
Review and validate delegated partner reports for accuracy, timeliness, and completeness.
Maintain documentation of oversight activities and corrective action plans.
Communicate effectively, both verbally and in writing.
Spend more than 50% of work time in front of a computer monitor.
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 andCertifications
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.