Job SummaryReporting 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 actions, or provide appropriate justification. Coordinate all required reviews and sign-offs for EDS/EDPS and APCD submissions. Develop internal capabilities and/or partner with vendors to support data optimization efforts, maintaining a catalog of data quality, operational efficiency, and submission enhancement opportunities. Participate, as required, in corporate project and strategic initiatives, including the development, evaluation, and presentation of business cases related to EDS/EDPS, APCD, and data optimization efforts. Oversee and monitor the processes for accepting, submitting, reconciling, and accurately tracking all supplemental submissions and deletes. Review and assess CMS HPMS memoranda and related regulatory guidance, identify operational and reporting impacts, and partner with internal stakeholders to ensure timely implementation of required actions, process changes, and compliance obligations
4. Analytics and Reporting: Coordinate with vendors and/or Actuarial teams to ensure that accurate and complete data is utilized for valuation, forecasting, targeting, and performance analyses supporting Medicare Advantage products. Manage and perform data analytics to support ongoing and emerging risk adjustment initiatives. Build, maintain, and enhance EDS/EDPS tieback processes and reporting for actuarial valuation exercises. Develop executive-level reports, dashboards, and PowerPoint presentations that clearly communicate reconciliation results, key findings, risks, opportunities, and recommendations.
5. General Management: The Manager will lead a team of 3-4 FTEs, including senior analysts and data leads, providing coaching, mentorship, performance management, and professional development to foster a high-performing team. This role is responsible for reviewing analytics, reporting, documentation, and technical deliverables to ensure quality, accuracy, and alignment with business objectives. The Manager will also promote strong collaboration across key stakeholders and ensure documentation is maintained in accordance with departmental standards, policies, and procedures.
Qualifications - what you need to perform the job
Certification and Licensure
Education
- Required (minimum): Bachelor's degree required.
Experience
Minimum 7-10 years in progressively responsible analytical roles; leadership, data management, and IT data governance experience in a complex operational setting or health plan environment required.
• Experience with data governance, data architecture, concept of data lineage, data quality control, and reporting
• Healthcare payer, provider, or consulting experience with Team leadership and stakeholder management experience
• Previous experience in either risk adjustment data analytics, reporting or process improvement in the health care / health insurance sector either for a health plan, provider group or management consultancy.
• Experience working with CMS, Medicare Advantage risk adjustment, EDS/EDPS and APCD submissions, state agencies, healthcare regulatory programs, health insurers or medical provider systems preferred.
• Previous experience managing a team as well as Process improvement and project management experience
• Vendor management experience preferred
Skill Requirements:
• Highly organized, self-motivated, detail-oriented, and energetic team player.
• Working knowledge of healthcare data (claim, member, and provider), data systems and financial reporting.
• Ability to understand and navigate complex business, operational, and regulatory environments.
• Demonstrated ability to build partnerships and collaborate effectively with internal and external stakeholders.
• Strong verbal and written communication skills, including one-on-one, small-group, and large-group presentations.
• Excellent judgment, critical thinking, problem-solving, and decision-making abilities.
• Strong process management, process improvement, and project management skills, with the ability to manage multiple priorities, drive operational efficiencies, and meet competing deadlines.
• Proven expertise in data management, data governance, internal controls, and IT data processes. Comfortable working with large, complex datasets from disparate sources and leveraging analytical tools to identify meaningful patterns, trends, and actionable insights.
• Strong experience with analytical, database, and reporting tools, including SQL (Oracle, SQL Server, Teradata), SAS, Databricks, Alteryx, and Tableau.
• Advanced proficiency in Microsoft Excel, PowerPoint, and Word.
• Experience developing and maintaining detailed documentation of policies, procedures, controls, and analytical processes.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):
• This is a hybrid role with an expectation of one day per week onsite at the Canton, MA office
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• Work may require multiple applications or documents to be open across multiple monitors simultaneously for analytical purposes.
• May be required to work additional hours beyond standard work schedule.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Salary Range$122,498.40 -$183,747.60
Compensation & Total Rewards OverviewThe annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.
Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/
