Analyst, Medicare Compliance

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The Role

The Medicare Compliance Analyst provides critical cross-functional support to ensure organizational adherence to the regulations established by the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage and Part D Prescription Drug Plans. This role is responsible for analyzing regulatory requirements to assess business impacts and ensure accurate, timely implementation. Key responsibilities include managing documentation for CMS audits and inquiries and evaluating operational policies and procedures for alignment with CMS mandates and internal standards.

The analyst will execute monitoring and auditing of Medicare operations to validate compliance, collaborate with internal business partners and external entities (such as vendors and CMS) to resolve identified compliance risks, and actively facilitate internal Compliance meetings.

Key Accountabilities/

Job Description:

• Audit & Monitoring:
  Execute auditing and monitoring of Medicare operational areas by evaluating performance reports, sample cases, workflows, and policies against CMS requirements and Audit Protocols.
• Reporting & Remediation:
  Formalize audit findings into comprehensive written reports for distribution to business leaders and present results during Compliance committee meetings. Review, refine, and track Corrective Action Plans (CAPs) submitted by business areas to remediate compliance gaps, and evaluate outcomes to validate successful implementation.
• Status Tracking & Reporting:
  Develop, maintain, and present executive summaries detailing the compliance status of assigned business areas for inclusion in internal dashboards. Generate ad-hoc reports, manage tracking documents, monitor deliverable timelines, and collaborate on project planning and problem resolution.
• Regulatory Analysis:
  Monitor, analyze, and summarize new CMS guidance and regulations to identify key business implications. Effectively disseminate this information to relevant business areas and track all required operational changes to completion.
• Subject Matter Expertise:
  Serve as the primary compliance subject matter expert for assigned business areas and represent Medicare Compliance in cross-functional enterprise work groups.
• Audit Coordination:
  Actively participate in the preparation, coordination, and execution of CMS audits.
• Continuous Learning & Advocacy:
  Maintain up-to-date knowledge of CMS rules and regulations by reviewing CMS bulletins, BCBSA notifications, and CMS communications. Promote a culture of compliance awareness across the organization through strategic communication, education, training, and ongoing monitoring.

Qualifications (Knowledge,

Skills and Abilities

):

• Highly organized and detail-oriented with advanced analytical and problem-solving capabilities.
• Exceptional written and verbal communication skills, with the ability to articulate complex regulatory concepts to diverse audiences.
• Extensive knowledge of Medicare Advantage and/or Prescription Drug Plan (Part
  
  D) regulatory requirements.
• Comprehensive understanding of health insurance plan operations (Blue Cross plan knowledge is highly preferred).
• Working knowledge of federal healthcare regulatory oversight agencies, including CMS and the Office of Inspector General (OIG).
• Strong grasp of foundational corporate Compliance Program requirements.
• Proactive initiative to identify operational challenges and recommend strategic, compliant solutions.
• High degree of professionalism with the proven ability to interact effectively with all levels of the organization.
• Demonstrated ability to collaborate effectively within cross-functional teams, as well as the capacity to work independently.
• Ability to apply sound judgment to complex compliance decisions, manage multiple concurrent projects, and meet strict deadlines with minimal supervision.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).

Education and Relevant

Experience:

• Bachelor's degree preferred, or equivalent professional work experience.
• 3–5+ years of business experience within a health insurance or managed care environment.
• 2–4+ years of dedicated…