Business Analytics, Senior Analyst

CVS Health

2d

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Data Analyst for claims & reporting is responsible for overseeing Medicaid claims operations, inventory management, quality assurance, and compliance monitoring. This role ensures timely and accurate processing of Medicaid claims in accordance with state and federal regulations, contractual requirements, and organizational performance standards.

Requirements

• Bachelor’s degree in Business, Healthcare Administration, or related field.
• 3+ years of claims experience in Medicaid.
• Strong understanding of Medicaid billing rules, HSCRC, provider types, benefit structures, and encounter reporting.
• Experience with major claims systems (e.g., QNXT).
• Problem solving mindset; adaptable, ability to analyze processes.
• Analytical skills with proficiency in Excel and claims data analysis.

Nice To Haves

• Experience with Medicaid managed care organizations (MCOs) or state Medicaid agencies.
• Knowledge of fee schedules, and Medicaid pricing methodologies.
• Background in payment integrity, claims audits, configuration testing, or encounter operations.

Responsibilities

• Manage daily Maryland Medicaid claims pend buckets to ensure timely and accurate claims adjudication and payment.
• Oversee inventory levels, turnaround times (TAT), backlog reduction, reduction of claims interest, suspended claims work queues, and provider dispute resolution.
• Drive improvements in auto-adjudication rates, accuracy, and first-pass resolution.
• Ensure all claims processes comply with: State Medicaid regulations and billing guidelines CMS requirements and Federal managed care rules Timely filing laws and encounter data reporting requirements
• Support readiness reviews, audits, Corrective Action Plans (CAPs), and state submissions.
• Implement QA programs to monitor claim accuracy, provider payment integrity, and policy adherence.
• Review and analyze claims performance dashboards, error trends, and key metrics (TAT, payment accuracy, denial rates, encounters, etc.).
• Partner with Finance on claims reserves, cost-of-care reporting, and reconciliation issues.
• Work closely with Configuration, Cotiviti and Claim Xten to resolve system issues, benefit configuration errors, and pricing or editing defects.
• Partner with Provider Relations to address contractual interpretation questions and recurring provider submission issues.
• Collaborate with Utilization Management/Medical Management on authorization-related claims issues.
• Coordinate with Compliance and Legal on regulatory changes and required process updates.
• Lead initiatives to streamline workflows, automate processes, reduce manual interventions, and improve accuracy.
• Drive root-cause analysis and implement sustainable corrective actions.
• Participate in the development of policy and procedure updates for Medicaid claims operations.

Benefits

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees