Government Programs Operations Analyst – R&R

Location: Hybrid (Local to NYC, Denver, CO or Charlotte, NC)

Position Summary:

The Government Programs Operations Analyst supports operational functions across Medicare, Medicaid, Exchange, and Commercial lines of business, with the primary responsibility of serving as the Reprocessing & Reversals (R&R) subject matter expert. The Analyst executes and validates R&R activities, provides operational and regulatory guidance, and works closely with Product and Development teams to design, test, and implement system and process enhancements. This role applies expertise in regulatory compliance and claims operations to resolve issues, maintain accurate documentation, and improve the integrity, efficiency, and scalability of operations.

Position Responsibilities:

• Serve as the primary Reprocessing & Reversals (R&R) subject matter expert, executing R&R activities and supporting continuous process improvement across applicable lines of business.
• Run and validate R&R activities, including complex claim reversals, reprocessing, retroactive changes, coordination-of-benefits adjustments, and other regulatory- or client-driven corrections.
• Partner with Product and Development teams to define R&R business requirements, evaluate proposed solutions, prioritize enhancements, and ensure functionality supports operational, regulatory, and client needs.
• Perform operational testing and validation of R&R enhancements, document outcomes and defects, and coordinate with Product and Development through implementation and post-production monitoring.
• Establish and maintain R&R procedures, controls, documentation, standard operating procedures, and audit-ready evidence to support consistent and compliant execution.
• Provide R&R guidance, training, and issue support to Operations, Client Services, Product, Development, and other internal stakeholders.
• Conduct root cause analysis of R&R and claims-processing issues, identify systemic trends, and implement corrective and preventive actions in collaboration with cross-functional partners.
• Perform day-to-day operational tasks related to claims processes, including PDE, Medicare Plan Finder, and Encounter Data submissions, while assessing downstream impacts of R&R activities.
• Support error handling and change management for PDE and encounter submissions, ensuring R&R outcomes align with CMS, state, and client requirements.
• Stay current on CMS guidance and regulatory updates, translating changes into actionable operational strategies.
• Share R&R knowledge and provide guidance to team members and cross-functional partners as needed.
• Maintain current knowledge of Medicare & Medicaid requirements to facilitate compliance of ongoing business operations.

Required Qualifications:

• 3+ years of experience in PBM or health plan operations, with experience supporting Medicare Part D, Medicaid, Exchange, and/or Commercial
• Proven subject matter expertise in pharmacy claim reprocessing and reversals, including complex claim corrections, operational controls, issue resolution, and downstream regulatory reporting impacts.
• Advanced MS Excel skills (pivot tables, complex formulas, data modeling); familiarity with SQL or other data tools is a plus.
• Demonstrated experience partnering with cross-functional teams to define business requirements, support solution design, perform user acceptance testing, manage defects, and implement operational enhancements.
• Strong analytical and problem-solving skills, with a track record of driving operational improvements.
• Strong written and verbal communication skills, with the ability to collaborate effectively with operational and technical stakeholders.
• Deep understanding of CMS compliance requirements and audit readiness.
• Highly organized, detail-oriented, and committed to delivering high-quality work.