[Remote] Medicare Advantage and DSNP Claims Analyst

Note: The job is a remote job and is open to candidates in USA. Mass General Brigham is a not-for-profit organization committed to advancing patient care and research. They are seeking a Medicare Advantage and DSNP Claims Analyst responsible for analyzing claims data to support operational decisions and ensure compliance with regulatory requirements. Responsibilities • Collects, monitors and analyzes Medicare Advantage and D-SNP Claims reporting to ensure timeliness, accuracy and compliance internally to support decisions on day-to-day operations, strategic planning, and/or specific business performance issues • Reviews, tracks, and communicates key performance indicators (KPIs) related to regulatory compliance, timeliness, and accuracy • Performs data validation of source-to-target data for data visuals and dashboards • Creates and updates claim reports • Collates, models, interprets, and analyzes data • Identifies trends and explains variances and trends in data, recommends actions, and escalates to leaders as appropriate • Identifies and documents enhancements to modeling techniques • Completes thorough quality assurance procedures, ensuring accuracy, reliability, trustworthiness, and validity of work • Provides audit support, both internal and external, which includes supporting the monthly Claims Compliance Monitoring and Organization Determination, Appeals, and Grievances (ODAG/ODR) reporting processes for all Medicare Advantage and D-SNP contracts • Works closely with internal departments, including but not limited to Enrollment, Customer Service, Reimbursement Strategy, Benefits, Product, Configuration, IT, and Digital Services to ensure seamless coordination and integration for claims data analysis • Collaborate with vendor partners to monitor and analyze claims reporting • Identifies operational inefficiencies or process bottlenecks and recommend improvements to enhance workflows, reduce costs, and improve member and provider satisfaction • Assist with the implementation and management of new medical health plan products or changes to existing plans • Support the creation and maintenance of medical health plan policies, procedures, and workflows to ensure compliance with CMS and EOHHS regulatory requirements • Performs other duties as assigned • Complies with all policies and standards Skills • Bachelor's Degree required; experience can be substituted for degree • At least 2-3 years of medical claims processing and/or data analysis within the health insurance or healthcare industry experience required • Medicare experience required • Massachusetts Medicaid experience required • Healthcare knowledge, particularly as it pertains to medical claims processing data, is preferred but not required • Working knowledge of relational databases, SQL, Power BI, data visualization, and business intelligence tools such as Tableau • Knowledge and application of statistical analyses, including variance analysis and statistical significance, are preferred • Project management skills and/or experience are a plus • Proficiency with Microsoft Office Suite, including Word, Excel and PowerPoint Benefits • Comprehensive benefits • Career advancement opportunities • Differentials • Premiums and bonuses as applicable • Recognition programs designed to celebrate your contributions and support your professional growth Company Overview • Mass General Brigham specializes in providing medical treatments and health diagnostics services. It was founded in 1994, and is headquartered in Somerville, Massachusetts, USA, with a workforce of 10001+ employees. Its website is https://www.massgeneralbrigham.org. Company H1B Sponsorship • Mass General Brigham has a track record of offering H1B sponsorships, with 77 in 2025, 61 in 2024, 93 in 2023, 70 in 2022, 80 in 2021, 29 in 2020. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job Apply To this Job