Regulatory Business Analyst

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Come join Peak Health – a fast-growing provider led health plan as a Regulatory Business Analyst. Your data management and analysis skills combined with your critical thinking will help us advance operational performance across Peak Health by transforming raw data into actionable intelligence that improves efficiency, throughput, quality, and member/provider experience.

The Regulatory Business Analyst will be an integral resource within the Operational Analytics department, and collaborate closely with peers and colleagues, across product, operations, medical management, provider contracting, and compliance to support the development and submission of regulatory reporting.

The ideal candidate will provide operational guidance and technical support for Center for Medicare & Medicaid (CMS) report deliverables. This position will utilize your understanding of government healthcare reporting, CMS data specifications, underlying data elements, and the ability to write SQL code to create standardized reports. The candidate will support internal stakeholders and data owners, clients, CMS, CMS vendors, and external data auditors. MINIMUM QUALIFICATIONS :

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Health Administration, Business Administration, Mathematics, Computer Science, Statistics, Information Systems, or a related field.
EXPERIENCE:

1. Five (5) years of experience monitoring, managing, manipulating, and drawing insights from data in a managed care company.

2. Three (3) years of experience working with claims, enrollment, appeals, and grievances data for regulatory submissions.

3. Epic Certification or Accreditation for Cogito, Caboodle Data Model, and Clarity Data Model or the ability to obtain such certification or accreditation within 60 days of hire.

4. Three (3) years of experience in data analytics to include software, modeling, ETL processes, data warehousing, and visualizations.

PREFERRED QUALIFICATIONS :

EXPERIENCE:

1. Three (3) years of experience working with Medicare, Medicaid, TPA, and/or ACA data.

2. Three (3) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, and quality outcomes.

3. Strong understanding of healthcare regulations (ACA, CMS guidelines, State regulatory agencies) and regulatory reporting.

4. Strong understanding of quality rating programs (e.g., Medicare Advantage Star Ratings, ACA QRS).

5. Experience with health plan operations and data architecture.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Monitor and analyze existing and new regulations affecting all Peak Health lines of business.

2. Interpret regulatory filing requirements, translate to business requirements, develop extracts, and compile data to meet reporting requirements.

3. Provide feedback on operational workflows to ensure data integrity and compliance with regulatory filing requirements.

4. Collect report requirements – interview and research business stakeholder needs; draft, edit and validate requirement documentation.

5. Work with stakeholders to develop and execute regulatory reporting roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective.

6. Support internal and external audit activities through compiling and researching claims, enrollment, premium, case notes, and other relevant info