Medicare Data Analyst (Onsite)

This position is fully onsite in our Doral office.

POSITION SUMMARY 

The Medicare Data Analyst position is responsible for data manipulation, report creation, and scorecard development to assist the Medicare Advantage HMO plans meet CMS compliance requirements for PBM oversight, HEDIS reporting, claims processing, CMS reporting and benefit set up and testing.

ESSENTIAL DUTIES & RESPONSIBILITIES

• Maintains and analyzes monthly Part D Reports: 

o Provider Reports

• Maintains Compliance Scorecard. 

• Maintains and analyzes CDAG Reports for timeliness. 

• Audits monthly EOB letters for accuracy. 

• Participate in desktop audits conducted by CMS such as Part D IPM (Improper Payment Measure) audit. 

• Fraud, Waste and Abuse (FWA) Reporting. 

• Analyzes and maintains PDE reporting through Acumen.

• Analyzes and maintains member FIR status as notified by PBM. 

• Maintains all Part D documents including Formulary, Pharmacy Directory and PA Criteria are current on the Solis website. 

• Monitor and Validate HEDIS data to and from Software Vendor. 

• Develop and maintain Provider Scorecards (HEDIS and Part D.)

• Support HEDIS team developing population target lists for intervention development. 

• Ability to research claims processing concerns and escalate any concerns.

• Assists with implementing standard policies and procedures. 

• Assures that corporate compliance is communicated, implemented, and monitored on an ongoing basis. 

• Participates in systems testing, develops procedures/controls, and provides recommendations for the ongoing improvement of the updated process. 

• Participates in group or committee discussions.

• Assist in CMS and HMO data audits conducted by CMS and internal audit teams.

• Assist in CMS and HMO data audits conducted by CMS and internal audit teams 

• Performs other related duties as assigned by management.

 QUALIFICATIONS & EDUCATION

• Bachelor’s degree in information technology or a related field is preferred.
• A 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. 
• Two (2) to four (4) years’ experience as a Data Analyst with HEDIS or Pharmacy Data management. 
• Experience with Microsoft Office applications including Excel, Word, Access, and Outlook. Must have data analysis and problem resolution skills.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

• Knowledge of HMO pharmacy claim processing and Medicare guidance related to Part D products.

• HEDIS Data Management and Measure related Knowledge. 

• Ability to review pharmacy claims and determine if the claim paid appropriately based on the benefit. 

• Ability to understand questions from external areas and articulate timely and accurate responses. 

• Knowledge of pharmacy processes and the ability to assist pharmacies with claims processing. 

• Ability and willingness to learn and take on more responsibilities based on activities with the team. 

• Experience with PBM systems and tools.

• Analytical, organizational, planning and problem-solving skills. 

• Understanding and knowledge of the business, products, programs, corporate organizational structure (including functional responsibilities), and basic research principles/methodologies. 

• Excellent written and verbal communication skills.

• Ability to lead and contribute to process improvement projects.

• Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations. 

• Administer and adhere to corporate and departmental policies, practices and procedures.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be provided to enable individuals with disabilities to perform the essential functions:

• The noise level in the work environment is usually moderate. 

• Fast-paced office environment. 

• Highly regulated environment. 

• Time frames to handle issues are in accordance with CMS time frames. 

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lift, and moves intermittently during working hours.