Posted 21 days ago
Medicare Data Operations Analyst I (Remote)
Job Type: Full-Time
In a few words
As a Medicare Financial Operations Analyst I, you will be responsible for executing processes for Medicare Part D products including Prescription Drug Events (PDE), Plan Finder files, Claims Reprocessing, Claims Adjustments and Monitoring and Oversight and also Medicaid encounters. You will be asked to conduct investigations and resolve complex issues. In this role, you’ll need to have strong analytical and communication skills. You should bring an inquisitive mind and be relentless in your search for answers and solutions to complex tasks. You will benefit from an ability to quickly grasp new cases and acquire platform knowledge through independent study, as well as interaction with other team members. The ability to discuss technical logic, awareness of when to be more or less detailed, and assurance evoked through an extensive understanding of our solutions and technology is essential.
The fundamentals for the job
- In this role, you will be the in-house Medicare go-to whiz on Medicare Part D products and Medicaid Encounters. This includes the related analysis, controls and reconciliations.
- It is expected you will have a deep understanding of PDE, Plan Finder and Encounters:
- Master CMS regulation regarding PDE and Plan Finder
- Be proficient calculating PDEs
- Can analyze and resolve PDE errors. This includes identifying situations where reprocessing and adjustments are required and then executing those procedures
- Perform monitoring and oversight of PDEs to ensure accuracy and compliance with regulations
- Can resolve Acumen incidents related to PDEs
- Understand and execute the quality assurance checks on Plan Finder files
- Can analyze pharmacy network, formulary and pricing changes on the PBM industry and how those affect the Plan Finder data submitted to CMS
- Can analyze and cross reference Plan Finder and PDE data and its importance in the calculation of CMS Star Rating program metrics
- Can pinpoint issues on the benefit configuration and POS adjudication to alert the business on possible impact to Plan Finder submission. Should be able to document finding and provide possible solutions
- Can understand and explain pricing hierarchy terms like AWP, WAC, discount percentages, MAC, lower of rules, etc.
- Have a reasonable understanding of pharmacy network terms like preferred, non-preferred, mail and LTC networks. Understand the concept of Out of network and the impact of those terms in the Plan Finder Pharmacy File
- Can understand and explain general drug terminology like drug hierarchy. Drug indicators like brand/generic, multi-source code, repacks, DESI codes, etc. Should understand how those impact the Plan Finder drug file.
- Familiar with the data elements on encounter transactions.
- Can adjust to different variance on the process depending State specific regulation.
- Keep up to date on CMS guidance related to Medicare Part D products and Medicaid Encounters. It is expected that you will also understand the guidance as well. Additionally, it is vital for you to reference guidance when analyzing and resolving issues.
- While conducting all activities, be able to identify and proactively suggest any margin for opportunities/risks.
- Assist in the documentation of business requirements for the Medicare Financial Operations modules enhancements.
- Help with documenting reporting requirements for Business Intelligence and Analytics to create new reports that will allow the Medicare Financial Operations team to conduct their work more efficiently and assist in decision-making.
- Provide client support and/or compliance/audit activities and collaborate in special projects and activities as assigned.
What you’re made of
The bold requirements
- 1-3 years’ relevant experience. Bachelor’s degree is a plus
- 3-5+ years of experience in an analytical, finance, project management or auditing role.
- Experience in healthcare or PBM is a great, big, fat plus
- Detail oriented problem solver, able to quickly spot trends and discrepancies, with financial acumen and strong analytical thinking skills.
- Ability to thrive in a high-growth, fast-paced, complex, shifting and uncertain business environment (but you are easygoing, straightforward and down to earth).
- Highly organized and self-motivated; able to manage multiple important investigations simultaneously
- Computer proficiency, understanding and use of Microsoft Office products, and Internet experience (basic digital skills you’ll use daily). Tableau and SQL experience is a plus.
- Ability to think analytically and consider all client configurations, as well as dive into the details and know when to operate at each level
- Strong technological acumen + industry experience make you a force to be reckoned with (notwithstanding a preposition at the end)
- You can communicate effectively (read, write, speak, daydream, argue, flatter, add, subtract, etc.) in English and plus if in Spanish
That something extra we d love to see
- Integrity: You don’t have a single dishonest or disloyal cell in your body. Down to the marrow, you can be trusted. This applies to everything about you in every area. Some people can find this quality boring, but it’s as rare as element 115 and just as precious.
- Analytical: You value the power of context & enjoy examining the past. You get the present by analyzing (sometimes over-analyzing) events leading up to it. Your strategic and critical mindset requires all the information to proceed.
- Responsible/Accountable: You take responsibility, own up to what you say and what you do. You don’t disappoint when you commit, as your word is your bond. You live by high values like honesty and loyalty and can be a bit judgmental. You stand by your actions and decisions, as well as those of your team.
- Problem solver: You provide comprehensive answers to complications or problems, keeping in mind both internal and external needs. You’re always part of the solution (not the precipitate).
- Detail oriented: Nothing gets by you and you rarely forget a thing. When learning some new procedure, you’re the type to take notes.
The above description is not intended to limit the scope of the job or to exclude other duties not mentioned. It is absolutely not a final set of specifications for the position. It’s simply meant to give readers an idea of what the role entails.
Abarca Health LLC is an equal employment opportunity employer and participates in E-Verify. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of gender, race/ethnicity, gender identity, sexual orientation, protected veteran status, disability, or other protected group status.