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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 workgroups.
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 experience in Medicare, Pharmacy Benefit Management, Compliance, or Operations
Previous experience in auditing, regulatory oversight, and data analysis is preferred.
This position is eligible for the following personas: eWorker, Mobile, Resident.
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
LocationHinghamTime TypeFull time
Salary Range: $72,630.00 - $88,770.00
The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?
We understand that the confidence gap (https://www.theatlantic.com/magazine/archive/2014/05/the-confidence-gap/359815/) and imposter syndrome (https://www.braintreepayments.com/blog/overcoming-imposter-syndrome/) can prevent amazing candidates coming our way, so please don't hesitate to apply. We'd love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It's in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture (https://careers.bluecrossma.org/us/en/culturepage) page. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join our Talent Community (https://careers.bluecrossma.org/us/en/jointalentcommunity?applyType=JTC) to stay "in the know" on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work (https://careers.bluecrossma.org/us/en/how-we-work) " Page.
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 Employer - veterans/disability. 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.
