Blue Cross Blue Shield of Massachusetts Analyst, Medicare Compliance in Hingham, Massachusetts

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This position will provide cross functional support to ensure compliance with the requirements set forth by The Centers for Medicare and Medicaid Requirements (CMS).

Analyzing compliance requirements to identify business impacts and ensure accurate and timely implementation, managing completion of supporting documentation for CMS requested materials, providing quality review of marketing materials prior to production as well as conducting a post production quality review, reviewing policies and procedures for adherence to CMS requirements, conduct monitoring and auditing of Medicare operations to validate compliance, working collaboratively with business partners both internally and externally (vendor or CMS) on identified compliance issues that require resolution, and facilitating Compliance meetings

Key Accountabilities:

  • The analyst will conduct auditing and monitoring of Medicare Operational areas, by reviewing business performance reports, cases, policies and procedures and workflows against CMS requirements to ensure compliance. Upon completion of the review of the materials, the Analyst will be required to formalize the results of the audit findings into a written audit report for distribution to the business area. Ability to review, edit, and track corrective action plans submitted by business area to remediate any identified compliance issues. Evaluate outcomes of corrective action to validate if corrective action has been successfully implemented.

  • Develop, maintain, and present written summaries of compliance status of assigned business areas to be included in internal dashboards and reports. The incumbent would also develop ad-hoc reports, tracking documents, work on special projects, update compliance documentation, monitor plan deliverable due dates and collaborate on problem resolution and project planning.

  • Read and summarize new CMS guidance and regulations, identify key business implications. Effectively communicate information to business areas. Track all required actions to completion. Serve as compliance subject matter expert for assigned business areas. Represent Medicare Compliance in cross functional workgroups.

  • Stay current with all CMS rules and regulations, by reading CMS bulletins, BCBS Association notifications, CMS webcasts and/or participating in other pertinent conference calls.

  • Participate in coordination of CMS audits, including site visits.

  • Promote compliance awareness throughout the organization with communication, education, training and monitoring.

Qualifications :(knowledge/skills/abilities/behaviors):

  • Detail oriented and organized individual with strong analytical and problem solving skills.

  • Ability to communicate effectively with strong written and verbal communication skills.

  • Extensive knowledge of the Medicare Advantage or Prescription Drug Plan program regulatory requirements. Knowledge of prescription drug benefit structures and/or the functions of a pharmacy benefit manager required.

  • Understanding of health insurance plan operations, Blue Cross plan knowledge preferred.

  • Understanding of federal health care regulatory oversight agencies, including CMS and OIG.

  • Understanding of Compliance Program requirements.

  • Demonstrate initiative to recognize problems and provide recommend solutions.

  • High degree of professionalism; ability to effectively interact with all levels of an organization.

  • Experience participating in cross-functional teams and ability to work as a team player.

  • Proven ability to also work independently without close supervision to apply sound judgment on a range of compliance issues/decisions and managing multiple projects and meeting scheduled deadlines.

  • Excellent Computer skills (Word, Excel, PowerPoint, Outlook).

Education and Relevant Experience:

  • Bachelor’s degree preferred or equivalent work experience.

  • 2-4+ years’ experience in Medicare, Pharmacy Benefit Management, Compliance, Operations, or Product Management preferred.

  • 3-5+ years of business experience in health insurance environment.

  • Previous auditing and data analysis experience preferred.


LocationHinghamTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.