Job description
Overview:
The Medicare Program Analyst serves as the subject matter expert (SME) on Medicare programmatic regulations for HNE. This role is responsible for assisting in product development, monitoring the market, and analyzing its trends to support Health New England’s growth initiatives. The Analyst acts as a consultant and collaborates with the Medicare, Compliance and other business leaders. The Analyst will model and validate the impact of new, current products, and programmatic changes as well as work with the financial optimization workgroup to assess for cost savings and revenue opportunities for HNE.
Responsibilities:
Medicare Program Analysis
- Serves as the company’s research specialist regarding Medicare methodologies and policies
- Provides Medicare subject matter expertise and assist in the implementation of programmatic changes based on regulatory guidance (support and responds to all program changes and updates)
- Analyzes Medicare market trends, examines competitor benefits and understand new market opportunities through tools such as TEG and DEFT research reports
- Develops summarized reporting for leadership executive team review utilizing aggregate data and information to assist decisions in the financial optimization work-group.
- Monitors both CMS regulations, listservs and other sources to identify existing payment practice and proposed changes
- Serves as the department’s project lead to drive changes as a result of regulatory changes, such as proposed and final Medicare regulations
and Medicare Provider Manual updates- Determines the scope and impact of any changes on Plan operations and seek to implement changes as necessary.
- Supports the business partners to accurately implement software updates that impact Medicare tools
- Assists in operationalizing strategic partnership by providing regulatory and programmatic support
- Collaborates with Finance, Accounting, Enrollment, Reconciliation, Provider Contracting/Relations, and Clinical teams to determine the impact of implementing Medicare relevant changes
- Responsible for requirements development, follow through and testing support on end-to-end implementation of new systems
- Participates in various work groups and committees to support product - growth initiatives and provides input into processes and workflows
that support timely system update - Attends state public hearings to gain insight on proposed regulatory changes
- Submits recommendations to the Product Benefit and Financial optimization work groups and supports these committee’s efforts as needed
- Collaborates with stakeholder departments to financial size and estimate the impact of financially impactful changes to methodologies and/or
fee schedule updates
Bid Support
- Conducts research on benefit and product enhancements and works with stakeholders on cost/benefit analysis considering the aggregate product and benefit changes for evaluation
- Validates Benefit Package entry into the CMS system
Audit Coordination
- Leads assigned audits and works with cross-functional departments to gather and deliver the necessary data to fulfill all audit requirements; including managing tracking grids, scheduling resources, and providing regular progress update reports to management
Bachelor’s degree in a related field and a minimum of 3 years’ of relevant experience, or the equivalent combination of training and experience,
in a fast paced, managed healthcare environment is required. Master’s Degree or graduate work in a related field preferred. Minimum of 3 years of experience and advanced knowledge of provider fee schedule, pricing and reimbursement methodologies, specifically Medicare methodologies, regulations, and dependent payment terms.
in a fast paced, managed healthcare environment is required. Master’s Degree or graduate work in a related field preferred. Minimum of 3 years of experience and advanced knowledge of provider fee schedule, pricing and reimbursement methodologies, specifically Medicare methodologies, regulations, and dependent payment terms.
- Deep understanding of the government standards and product development
- Experience working with Medicare and commercial claims coding rules/ regulatory requirements
- Demonstrated acumen for managing complex financial payment methodologies with a strong medical claims auditing for payment accurate and/or contracting
- Demonstrated knowledge and solid understanding of Medicare
- Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve
- Flexible, highly motivated, self-starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision
- Strong analytical skills coupled with good communication skills, both oral and written, ability to interact well with others at all management levels
- Demonstrated proficiency using MS tools, including, with an interest or skill set to leverage reporting tools for analytical purposes
- Strong organizational skills and strong internal customer/business partnership/service skills
- Strong background in working with technical teams to implement complex business requirements, subsequent testing, and workflow closure
- Valid driver's license required
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