Regulatory Business Analyst

Peak Health is a fast-growing provider-led health plan. The Regulatory Business Analyst will support regulatory reporting by analyzing healthcare data, translating filing requirements into business requirements, developing standardized SQL-based reports, and collaborating with operational, compliance, CMS, and audit stakeholders.

Responsibilities:

• 1. Monitor and analyze existing and new regulations affecting all Peak Health lines of business
• 1. Interpret regulatory filing requirements, translate to business requirements, develop extracts, and compile data to meet reporting requirements
• 1. Provide feedback on operational workflows to ensure data integrity and compliance with regulatory filing requirements
• 1. Collect report requirements – interview and research business stakeholder needs; draft, edit and validate requirement documentation
• 1. 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
• 1. Support internal and external audit activities through compiling and researching claims, enrollment, premium, case notes, and other relevant information; presents findings to leadership
• 1. Communicate results of analysis effectively and regularly to business stakeholders; identify and recommends action opportunities for operational workflows, reporting processes, and/or efficiencies
• 1. Support the regulatory reporting strategy, objectives, and initiatives through the creation of reports and/or analysis to drive efficiency for the Plan
• 1. Other duties as assigned or requested

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
• Ability to sit, stand, walk, and use standard office equipment for extended periods
• Occasional travel to office may be required
• 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
• 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