Business System Analyst – Medicare Operations

CGI•Canton, MA

9d•Hybrid

About The Position

CGI is seeking a Medicare Operations Business Analyst who will serve as a subject matter expert and process driver within a healthcare payer organization, supporting the end-to-end lifecycle of Medicare Advantage and Part D programs. This role bridges CMS regulatory requirements with operational delivery — translating complex compliance mandates into actionable workflows, member communications, and system requirements. The ideal candidate combines deep knowledge of Medicare regulations with strong analytical skills and the ability to partner across clinical, IT, compliance, and vendor teams. This role must be performed from the client site in Canton, MA (Hybrid)

Requirements

7+ years of experience in healthcare payer operations with a focus on Medicare Advantage and/or Part D.
Demonstrated knowledge of CMS regulations, the Medicare Managed Care Manual, and Part D Policy and Procedures.
Hands-on experience with Part D member communications including Coverage Determination, Formulary Exception, and Appeal letters.
Experience supporting enrollment operations and CMS transaction processing (834 files, HPMS).
Proficiency with business analysis tools: process mapping (Visio, Lucidchart), requirements documentation, and UAT facilitation.
Strong data analysis skills; proficiency in Excel;
Excellent written and verbal communication skills with the ability to translate regulatory language for operational audiences.
Bachelor's degree in health administration, Business, Public Health, or a related field.

Nice To Haves

Data Analysis
ETL
Health Care Analytics
Health Care Payers
Oracle
Problem Management
Requirement Management
SQL
User acceptance testing

Responsibilities

Serve as a business-side subject matter expert on CMS regulations, including the Medicare Managed Care Manual, Part D Policy and Procedures, and annual Call Letter requirements.
Monitor and interpret CMS guidance updates, translating regulatory changes into actionable business requirements for operations and IT teams.
Coordinate internal CMS audit readiness activities including HPMS submissions, mock audits, and corrective action plan (CAP) tracking.
Partner with compliance and legal teams to ensure all operational processes meet CMS standards and timelines.
Manage the business requirements, content governance, and quality assurance for all Medicare Part D member-facing correspondence.
Own the lifecycle of Coverage Determination letters, Formulary Exception notices, Redetermination letters, Transition Fill notices, and Low-Income Subsidy (LIS/Extra Help) communications.
Ensure all letters comply with CMS model language requirements, plain language standards, and culturally and linguistically appropriate services (CLAS) mandates.
Maintain a letter inventory and version-control repository; track CMS-required revision cycles and model language updates.
Support Medicare enrollment operations including Initial Enrollment, Annual Enrollment Period (AEP), Special Enrollment Period (SEP), and disenrollment processing.
Analyze enrollment data to identify trends, discrepancies, and process improvement opportunities.
Assist in resolution of member eligibility issues, retroactive enrollment adjustments, and CMS discrepancy reports.
Document and maintain business process workflows for Part D coverage determinations, exceptions, appeals, and grievances (CDAG).
Ensure timeliness and compliance with CMS-required decision timeframes.
Partner with the pharmacy and clinical teams on formulary management, step therapy, and prior authorization criteria.
Elicit, document, and validate business requirements for Medicare-related system enhancements and operational projects.
Develop process maps, workflow diagrams, use cases, user stories, and functional specifications.
Conduct gap analyses between current-state operations and CMS requirements or best practices.
Lead and facilitate cross-functional working groups, stakeholder reviews, and UAT planning.
Produce dashboards, KPI reports, and trend analyses to support operational and executive decision-making.
Apply continuous improvement methodologies (Lean, Six Sigma) to drive efficiency gains in Medicare operations.