Technical Analyst – Healthcare Payer
2 - 5 years
United States
Contract
Remote
1 month ago
About the role
Role - Technical Analyst
Position - Remote
We are seeking a Technical Analyst with strong experience in Medical Management compliance reporting to support regulatory and operational reporting needs. The role will focus on development, validation, and submission of compliance reports such as ODAG (Organization Determination Appeals and Grievances), CDAG (Coverage Determination Appeals and Grievances), and other CMS-mandated reporting for Medical Management functions. This role requires close collaboration with business (UM/CM teams), data teams, and IT stakeholders to ensure accuracy, timeliness, and compliance with regulatory standards.
Key Responsibilities
Required Skills & Experience
Preferred Skills
Position - Remote
We are seeking a Technical Analyst with strong experience in Medical Management compliance reporting to support regulatory and operational reporting needs. The role will focus on development, validation, and submission of compliance reports such as ODAG (Organization Determination Appeals and Grievances), CDAG (Coverage Determination Appeals and Grievances), and other CMS-mandated reporting for Medical Management functions. This role requires close collaboration with business (UM/CM teams), data teams, and IT stakeholders to ensure accuracy, timeliness, and compliance with regulatory standards.
Key Responsibilities
- Develop, enhance, and maintain Medical Management compliance reports including ODAG, CDAG, and related CMS submissions
- Analyze regulatory requirements and translate them into technical specifications and reporting logic
- Perform data validation, reconciliation, and audit support to ensure report accuracy and compliance readiness
- Partner with Utilization Management (UM) and Care Management (CM) teams to refine reporting requirements
- Work with data sources across Core Admin, UM platforms (e.g., MHK), and downstream systems
- Support submission cycles, including pre-validation, error resolution, and final reporting deliverables
- Ensure compliance with CMS guidelines and internal audit controls
- Identify opportunities for automation and optimization in reporting processes
Required Skills & Experience
- 5+ years of experience in Healthcare Payer domain (Medicare Advantage preferred)
- Hands-on experience with Medical Management compliance reporting (ODAG, CDAG, CMS reporting)
- Strong understanding of Utilization Management (UM) and Care Management (CM) workflows
- Experience working with healthcare data models and regulatory datasets
- Proficiency in SQL, data analysis, and reporting tools
- Experience with systems such as MHK (MedHOK), Core Admin platforms (IKA/QNXT/Facets or similar)
- Familiarity with data validation, reconciliation, and audit processes
- Strong analytical and problem-solving skills
Preferred Skills
- Experience with CMS audit support and compliance submissions
- Exposure to Azure-based data environments or modern data platforms
- Knowledge of EDI transactions (837/835) and claims lifecycle
- Experience in automation or reporting optimisation initiatives