Medicare Advantage and DSNP Claims Analyst

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Responsible for extracting knowledge and insights from data in order to investigate business/operational problems through a range of data preparation, modeling, analysis, and/or visualization techniques.

Essential Functions

• Collects, monitors and analyzes Medicare Advantage and D-SNP Claims reporting to ensure timeliness, accuracy and compliance internally to support decisions on day-to-day operations, strategic planning, and/or specific business performance issues.
• Reviews, tracks, and communicates key performance indicators (KPIs) related to regulatory compliance, timeliness, and accuracy.
• Performs data validation of source-to-target data for data visuals and dashboards.
• Creates and updates claim reports.
• Collates, models, interprets, and analyzes data.
• Identifies trends and explains variances and trends in data, recommends actions, and escalates to leaders as appropriate.
• Identifies and documents enhancements to modeling techniques.
• Completes thorough quality assurance procedures, ensuring accuracy, reliability, trustworthiness, and validity of work.
• Provides audit support, both internal and external, which includes supporting the monthly Claims Compliance Monitoring and Organization Determination, Appeals, and Grievances (ODAG/ODR) reporting processes for all Medicare Advantage and D-SNP contracts.
• Works closely with internal departments, including but not limited to Enrollment, Customer Service, Reimbursement Strategy, Benefits, Product, Configuration, IT, and Digital Services to ensure seamless coordination and integration for claims data analysis.
• Collaborate with vendor partners to monitor and analyze claims reporting.
• Identifies operational inefficiencies or process bottlenecks and recommend improvements to enhance workflows, reduce costs, and improve member and provider satisfaction.
• Assist with the implementation and management of new medical health plan products or changes to existing plans.
• Support the creation and maintenance of medical health plan policies, procedures, and workflows to ensure compliance with CMS and EOHHS regulatory requirements.
• Performs other duties as assigned
• Complies with all policies and standards
  
  

Qualifications

Education

• Bachelor's Degree required; experience can be substituted for degree
  
  

Experience

• At least 2-3years of medical claims processing and/or data analysis within the health insurance or healthcare industry experience required
• Medicare experience required.
• Massachusetts Medicaid experience required.
  
  

Knowledge, Skills, And Abilities

• Healthcare knowledge, particularly as it pertains to medical claims processing data, is preferred but not required.
• Working knowledge of relational databases, SQL, Power BI, data visualization, and business intelligence tools such as Tableau.
• Knowledge and application of statistical analyses, including variance analysis and statistical significance, are preferred.
• Project management skills and/or experience are a plus.
• Proficiency with Microsoft Office Suite, including Word, Excel and PowerPoint.
  
  

Additional Job Details (if Applicable)

Working Conditions

• This is a remote role that can be done from most US states
• This role is 40 hours/week with five 8-hour days, with a typical schedule of 8:30 am to 5:00 pm
  
  

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$62,400.00 - $90,750.40/Annual

Grade

6

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement

8925 Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran’s Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership “looks like” by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.