Note: The job is a remote job and is open to candidates in USA. Blue Cross Blue Shield of Massachusetts is a community-focused health plan dedicated to transforming healthcare. The Medicare Compliance Analyst plays a critical role in ensuring compliance with CMS regulations for Medicare Advantage and Part D plans through auditing, monitoring, and collaboration with internal and external stakeholders.
Responsibilities
- Execute auditing and monitoring of Medicare operational areas by evaluating performance reports, sample cases, workflows, and policies against CMS requirements and Audit Protocols
- 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
- 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
- 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
- Serve as the primary compliance subject matter expert for assigned business areas and represent Medicare Compliance in cross-functional enterprise workgroups
- Actively participate in the preparation, coordination, and execution of CMS audits
- 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
Skills
- 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
- 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)
- 3–5+ years of business experience within a health insurance or managed care environment
- 2–4+ years of dedicated experience in Medicare, Pharmacy Benefit Management, Compliance, or Operations
- High school degree or equivalent required unless otherwise noted above
- Bachelor's degree preferred, or equivalent professional work experience
- Comprehensive understanding of health insurance plan operations (Blue Cross plan knowledge is highly preferred)
- Previous experience in auditing, regulatory oversight, and data analysis is preferred
Benefits
- Paid time off
- Medical/dental/vision insurance
- 401(k)
- A suite of well-being benefits to eligible employees
Company Overview