Medicare Advantage and DSNP Claims Analyst

Mass General Brigham Health Plan
United States, Massachusetts, Somerville
399 Revolution Drive (Show on map)
Jan 05, 2026
Responsible for extracting knowledge and insights from data in order to investigate business/operational problems through a range of data preparation, modeling, analysis, and/or visualization techniques. Essential Functions -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 Education Bachelor's Degree required; experience can be substituted for degree Experience At least 2-3years of medical claims processing and/or data analysis within the health insurance or healthcare industry experience required Medicare experience required. Massachusetts Medicaid experience required. Knowledge, Skills, and Abilities 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. Working Conditions This is a remote role that can be done from most US states This role is 40 hours/week with five 8-hour days, with a typical schedule of 8:30 am to 5:00 pm Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. By embracing diverse skills, perspectives and ideas, we choose to lead. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment.