Medicare Operations Analyst

Overview The Medicare Operations Analyst is responsible for ensuring operational excellence across

delegated entities during implementation and post Go-Live implementation for Medicare DSNP

program. In collaboration with the respective department, this role oversees implementation and

post-implementation day-to-day operations including enrollment, claims processing,

utilization/case management (UM/CM), and call center performance. The Analyst will monitor,

audit, and collaborate with delegated partners to ensure adherence to CMS regulations,

organizational policies, and contractual requirements. Review daily/weekly/monthly operational

reports.

Responsibilities ▪ Validates file intake, effective dates, transaction codes (add/change/term), and

retroactivity handling.

▪ Validates compliance with CMS enrollment rules, including effective dates and

disenrollment procedures.

▪ Monitors enrollment files and reconciliation processes to ensure timely and accurate

member onboarding.

▪ Confirms vendor logic for ID cards, ANOCs/EOCs, welcome kits, PCP assignments.

▪ Validates fee schedules, OON rules, bundling/unbundling edits, prior auth linkages.

▪ Validates IVR menus, skills-based routing, disaster recovery, and call recording

retention.

▪ Reviews scripts, FAQs, compliance call flows (no steering/misleading), language access

and interpreter processes.

▪ Ensures delegated UM/CM programs meet regulatory standards.

▪ Develops test plans covering unit, system, integration, regression, User Acceptance

Testing (UAT), and operational readiness (ORR) during implementation.

▪ Manages log and prioritize defects; verifies fixes; manages exit criteria for each phase

during implementation.

▪ Serves as the primary liaison for delegated entities managing enrollment, claims,

UM/CM, and call center operations. Oversees delegated claims processing for accuracy,

timeliness, and adherence to CMS requirements.

▪ Identifies and resolves systemic issues impacting claims adjudication and payment

integrity.

▪ Reviews UM reports and dashboards to identify trends, outliers, and potential

compliance risks.

▪ Monitors delegated call center performance reports for compliance with CMS call

handling standards, including timeliness and accuracy of information.

▪ Reviews member complaint logs and ensures resolution within required timeframes.

▪ Stays current with CMS regulations, HPMS memos, and industry best practices.

▪ Supports readiness for CMS audits and compliance reviews.

▪ Conducts regular audits and monitoring activities to ensure compliance with CMS

guidelines and organizational standards.

▪ Reviews and validates reports from delegated partners for accuracy, timeliness, and

completeness.

▪ Maintains documentation of oversight activities and corrective action plans.

Qualifications

Education and Experience

Bachelor’s degree in healthcare administration, Business, or related

field (or equivalent experience). In lieu of a degree, a minimum of

eight (8) years of relevant health plan operations experience is

required. Three (3) to five (5) years of experience in Medicare DSNP

operations. Strong knowledge of CMS regulations. Experience with

auditing, compliance monitoring, and performance reporting.

Special Skills, Licenses and

Certifications

Familiarity with NCQA standards. Experience working with delegated

vendors. Experience supporting CMS program audits and corrective

action plans. Excellent communication, analytical, and problemsolving skills.

Performance Based Competencies

Ability to evaluate plan performance. Develop and execute strategic

business initiatives. Perform policy development and implementation

in the areas of Medicare and Medi-Cal. Conduct compliance and

regulatory-related research and analysis to support decision-making

and planning for major strategic initiatives. Communicate effectively,

both verbally and in writing. Perform Project Management activities.

Work Environment And Physical Demands

Ability to use a computer keyboard and other business machines. More

than 50% of work time is spent in front of a computer monitor. When

required, ability to move, carry, or lift objects of varying size, weighing

up to 35 lbs

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures as they may from time to time be updated.

HIRING RANGE:

$106,667.05 - $138,667.16

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform.

The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.