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.

▪ 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.

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.