Business System Analyst – Medicare Operations

About the role

The Medicare Operations Business Analyst serves 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.

Responsibilities

• 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.
• 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.
• 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.
• 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.
• 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.

Requirements

• 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.