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

Education

• Bachelors 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.

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

399 Revolution Drive

40

Regular

Day (United States of America)

Pay Range

$62400.00 - $90750.40/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 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.

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 Veterans 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 .

Mass General Brigham Competency Framework