Manager, Reporting and Analytics - Medicare Advantage

Point32Health, Inc.; United States; On-site; USD 120,000 - 160,000; Full time

Job summary

Point32Health, Inc. is seeking a Manager of Reporting and Analytics - Medicare Advantage who will apply advanced business, analytical, technical, and leadership skills to ensure the accuracy, completeness, and integrity of risk adjustment data submissions to CMS.

This role will optimize risk score accuracy and support revenue performance across all Medicare Advantage products, with oversight of APCD reporting to six state agencies.

Responsibilities

• Oversee Medicare Advantage and APCD data submissions, governance, and reporting to ensure accuracy and compliance.
• Collaborate with Actuarial, Claims, Membership Operations, IT and vendors; coordinate APCD submissions with six state agencies.
• Oversee CMS submissions for multiple products and APCD reporting; ensure data quality and remediation of issues.

Job description

Who We Are

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health .

Job Summary

Reporting to the Director of Risk Adjustment Reporting and Analytics, the Manager of Reporting and Analytics - Medicare Advantage will apply a blend of advanced business, analytical, technical, and leadership skills to ensure the accuracy, completeness, and integrity of risk adjustment data submissions to CMS. This role will optimize risk score accuracy, support revenue performance across all Medicare Advantage products, and ensure the timely, accurate, and compliant submission and reporting of All-Payer Claims Database (APCD) files to six state agencies.

This individual will synthesize large data sets, complex information and work effectively across business areas including Member Operations, Provider Information, Claims, Information Technology (IT) and Actuarial. The Manager will possess a strong understanding of data architecture, data lineage, and relational databases and will actively partner with IT teams on solution design, data flow analysis, root-cause investigations, implementation planning, and quality assurance of IT deliverables.

The Manager will lead a team of 3-4 senior analysts and data leads, providing coaching, mentorship, performance management, and professional development to build a highly engaged and high-performing team. In addition, the Manager will oversee all EDS/EDPS submissions for Point32Health and serve as the organization's subject matter expert for Medicare Advantage Encounter Data Processing System (EDS/EDPS) submissions and APCD reporting.

Job Description

Key Responsibilities/Duties - what you will be doing (top five):

• 1. Medicare Advantage and APCD Data Governance, Reporting, and Submission Oversight: Be responsible for the planning, execution, program implementation, and monitoring of Medicare Advantage and All-Payer Claims Database (APCD) data submission and reporting efforts. Regularly review the effectiveness, accuracy, and compliance of claims, supplemental data, and APCD submission processes, infrastructure, and reporting; recommend design enhancements and implement changes as needed. Oversee the maintenance of data controls, dashboard reporting, and routine data reconciliations, and provide regular updates to management. Routinely present key issues, business updates, and performance metrics related to Medicare Advantage risk adjustment.
• 2. Collaboration and Stakeholder Management: Collaborate closely with Actuarial on Medicare Advantage analytics, program, and provider-level analyses, and targeting. Partner with internal stakeholders, including Claims, Membership Operations, Provider Information, External Vendors, and IT, to ensure that process enhancements and data management mechanisms are developed, maintained, and monitored on an ongoing basis. Lead communication, coordination, issue resolution, and compliance-related activities with six state agencies related to All-Payer Claims Database (APCD) submissions, ensuring timely, accurate, and compliant reporting. Participate in and contribute to strategic planning efforts and annual risk adjustment business plan development. Participate in CMS and industry calls and monitor changes in regulations and technical specifications affecting EDS/EDPS and APCD submissions. Serve as the organization's subject matter expert for EDS/EDPS (Encounter Data Processing System) and APCD reporting requirements, both internally and in interactions with CMS and state regulatory agencies.
• 3. Data Optimization, Submissions, and Integrity: Oversee data management and submission responsibilities for EDS/EDPS CMS submissions for Massachusetts HMO, PPO, SCO, Unify products and Connecticut HMO and PPO products, as well as All-Payer Claims Database (APCD) submissions to six state agencies. Ensure timely, complete, accurate, and compliant data submissions and reporting. Review CMS-reported errors, outliers, and data quality findings, and collaborate with Actuarial, IT, Operational, and vendor partners to remediate issues, implement corrective actio