Regulatory Business Analyst

WVU Medicine • Home Work - PA (Remote), PA

1d • Remote

About The Position

Peak Health is seeking a Regulatory Business Analyst to join their fast-growing provider-led health plan. This role is crucial for advancing operational performance by transforming raw data into actionable intelligence to improve efficiency, throughput, quality, and member/provider experience. The Regulatory Business Analyst will be a key member of the Operational Analytics department, collaborating with various teams including product, operations, medical management, provider contracting, and compliance to support the development and submission of regulatory reporting. The ideal candidate will offer operational guidance and technical support for Center for Medicare & Medicaid (CMS) report deliverables, leveraging their understanding of government healthcare reporting, CMS data specifications, and SQL to create standardized reports. This position involves supporting internal stakeholders, data owners, clients, CMS, CMS vendors, and external data auditors.

Requirements

• Bachelor’s Degree in Health Administration, Business Administration, Mathematics, Computer Science, Statistics, Information Systems, or a related field.
• Five (5) years of experience monitoring, managing, manipulating, and drawing insights from data in a managed care company.
• Three (3) years of experience working with claims, enrollment, appeals, and grievances data for regulatory submissions.
• Epic Certification or Accreditation for Cogito, Caboodle Data Model, and Clarity Data Model or the ability to obtain such certification or accreditation within 60 days of hire.
• Three (3) years of experience in data analytics to include software, modeling, ETL processes, data warehousing, and visualizations.
• Strong programming skills with query languages such as SQL and the ability to perform effective queries from multiple tables and databases.
• Experience with querying tools such as Microsoft SQL Server Management Studio or SAS Enterprise Guide.
• Experience with data visualization tools such as Tableau or PowerBI.
• Strong problem-solving and quantitative abilities.
• Excellent communication and collaboration skills.
• Attention to detail.
• Experience with regulated government products – ACA, Medicare, and Medicaid products.
• Working knowledge of claims, utilization management, member, and/or provider data.
• Effective time management and organizational skills.
• Work independently as well as in a team environment.
• Proficient computer skills, including experience with Microsoft Office Suite such as Excel functionality (pivot tables, vlookups, macros, etc.).
• Strong problem solving and quantitative abilities.
• Understanding of business function interdependencies within a health plan setting.

Nice To Haves

• Three (3) years of experience working with Medicare, Medicaid, TPA, and/or ACA data.
• Three (3) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, and quality outcomes.
• Strong understanding of healthcare regulations (ACA, CMS guidelines, State regulatory agencies) and regulatory reporting.
• Strong understanding of quality rating programs (e.g., Medicare Advantage Star Ratings, ACA QRS).
• Experience with health plan operations and data architecture.

Responsibilities

• Monitor and analyze existing and new regulations affecting all Peak Health lines of business.
• Interpret regulatory filing requirements, translate to business requirements, develop extracts, and compile data to meet reporting requirements.
• Provide feedback on operational workflows to ensure data integrity and compliance with regulatory filing requirements.
• Collect report requirements – interview and research business stakeholder needs; draft, edit and validate requirement documentation.
• Work with stakeholders to develop and execute regulatory reporting roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective.
• Support internal and external audit activities through compiling and researching claims, enrollment, premium, case notes, and other relevant information; presents findings to leadership.
• Communicate results of analysis effectively and regularly to business stakeholders; identify and recommends action opportunities for operational workflows, reporting processes, and/or efficiencies.
• Support the regulatory reporting strategy, objectives, and initiatives through the creation of reports and/or analysis to drive efficiency for the Plan.
• Other duties as assigned or requested.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level