Business System Analyst â Medicare Operations

Job order - J0526‑1351 - Permanent Full Time Title Business System Analyst – Medicare Operations Category Business Analysis (functional and technical) City Canton, Massachusetts, United States Job Description CGI is seeking a Medicare Operations Business Analyst who will serve as a subject matter expert and process driver within a healthcare payer organization, supporting the end-to-end lifecycle of Medicare Advantage and Part D programs. This role bridges CMS regulatory requirements with operational delivery – translating complex compliance mandates into actionable workflows, member communications, and system requirements. The ideal candidate combines deep knowledge of Medicare regulations with strong analytical skills and the ability to partner across clinical, IT, compliance, and vendor teams. This role must be performed from the client site in Canton, MA (Hybrid). Duties and Responsibilities CMS Compliance & Regulatory Operations Serve as a business-side subject matter expert on CMS regulations, including the Medicare Managed Care Manual, Part D Policy and Procedures, and annual Call Letter requirements. Monitor and interpret CMS guidance updates, translating regulatory changes into actionable business requirements for operations and IT teams. Coordinate internal CMS audit readiness activities including HPMS submissions, mock audits, and corrective action plan (CAP) tracking. Partner with compliance and legal teams to ensure all operational processes meet CMS standards and timelines. Part D Letters & Member Communications Manage the business requirements, content governance, and quality assurance for all Medicare Part D member-facing correspondence. Own the lifecycle of Coverage Determination letters, Formulary Exception notices, Redetermination letters, Transition Fill notices, and Low‑Income Subsidy (LIS/Extra Help) communications. Ensure all letters comply with CMS model language requirements, plain language standards, and culturally and linguistically appropriate services (CLAS) mandates. Maintain a letter inventory and version‑control repository; track CMS‑required revision cycles and model language updates. Enrollment & Eligibility Operations Support Medicare enrollment operations including Initial Enrollment, Annual Enrollment Period (AEP), Special Enrollment Period (SEP), and disenrollment processing. Analyze enrollment data to identify trends, discrepancies, and process improvement opportunities. Assist in resolution of member eligibility issues, retroactive enrollment adjustments, and CMS discrepancy reports. Coverage Determinations & Appeals Document and maintain business process workflows for Part D coverage determinations, exceptions, appeals, and grievances (CDAG). Ensure timeliness and compliance with CMS‑required decision timeframes. Partner with the pharmacy and clinical teams on formulary management, step therapy, and prior authorization criteria. Business Analysis & Process Improvement Elicit, document, and validate business requirements for Medicare‑related system enhancements and operational projects. Develop process maps, workflow diagrams, use cases, user stories, and functional specifications. Conduct gap analyses between current‑state operations and CMS requirements or best practices. Lead and facilitate cross‑functional working groups, stakeholder reviews, and UAT planning. Produce dashboards, KPI reports, and trend analyses to support operational and executive decision‑making. Apply continuous improvement methodologies (Lean, Six Sigma) to drive efficiency gains in Medicare operations. Required Qualifications 7+ years of experience in healthcare payer operations with a focus on Medicare Advantage and/or Part D. Demonstrated knowledge of CMS regulations, the Medicare Managed Care Manual, and Part D Policy and Procedures. Hands‑on experience with Part D member communications including Coverage Determination, Formulary Exception, and Appeal letters. Experience supporting enrollment operations and CMS transaction processing (834 files, HPMS). Proficiency with business analysis tools: process mapping (Visio, Lucidchart), requirements documentation, and UAT facilitation. Strong data analysis skills; proficiency in Excel. Excellent written and verbal communication skills with the ability to translate regulatory language for operational audiences. Bachelor's degree in health administration, Business, Public Health, or a related field. Compensation and Benefits Compensation range: $80,600.00 – $172,400.00. Competitive compensation Comprehensive insurance options Matching contributions through the 401(k) plan and the share purchase plan Paid time off for vacation, holidays and sick time Paid parental leave Learning opportunities and tuition assistance Wellness and Well‑being programs Equal Opportunity Statement Qualified applicants will receive consideration for employment without regard to their race, ethnicity, ancestry, color, sex, religion, creed, age, national origin, citizenship status, disability, pregnancy, medical condition, military and veteran status, marital status, sexual orientation or perceived sexual orientation, gender, gender identity, and gender expression, familial status or responsibilities, reproductive health decisions, political affiliation, genetic information, height, weight, or any other legally protected status or characteristics to the extent required by applicable federal, state, and/or local laws where we do business. CGI will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with CGI’s legal duty to furnish information. #J-18808-Ljbffr