CMS Regulatory Business Analyst (NO C2C)

Why work at OpTech? OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits on the first day of employment, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, pleas e visit our website at www.optechus.com. Job Title: CMS Regulatory Business Analyst Engagement Overview: • We are seeking a CMS Regulatory Business Analyst to bridge regulatory requirements with operational execution across Medicare Advantage and other risk-bearing programs. This role ensures CMS compliance, mitigates operational risk, and supports the overall success of the organization’s Risk Adjustment initiatives. • The ideal candidate will have strong expertise in risk adjustment, interpreting regulatory guidance, and helping business teams implement compliant, efficient solutions. • Additionally, this role involves conducting industry research to identify best practices that minimize risk while maximizing member health outcomes. • Success in this position requires critical thinking, cross-functional collaboration, and the ability to thrive in a fast-paced, high-stakes environment. • This role directly contributes to accurate RAF optimization, sustainable reimbursement outcomes, and organizational compliance. Key Responsibilities: Business Requirements Gathering • Research, interpret, and apply CMS regulations and relevant healthcare laws for risk adjustment programs. • Collaborate with stakeholders to gather and document business requirements, translating them into actionable functional specifications for business teams. Risk Management: • Develop and implement risk assessment and monitoring processes to mitigate compliance risks in risk adjustment activities. • Track and manage corrective action plans to address identified deficiencies. Process Improvement: • Analyze existing processes and controls to strengthen compliance and operational efficiency. • Support documentation, implementation, and monitoring of process improvements and controls aligned with best practices. Data Analysis & Reporting: • Analyze large datasets to identify trends, patterns, and anomalies related to risk adjustment and compliance. • Use business intelligence tools and reporting platforms to create dashboards and reports monitoring risk adjustment performance. • Interpret data to support compliance and operational decision-making. Project & Stakeholder Management: • Lead or support projects related to risk adjustment initiatives and compliance. • Collaborate effectively with clinical staff, IT teams, management, and external partners to implement solutions. Required Skills & Qualifications: • Knowledge of Medicare Advantage and other risk adjustment programs. • Strong understanding of CMS guidelines, HIPAA, and healthcare regulations affecting risk adjustment. • Proficiency in data analysis tools, BI platforms, and MS Office applications. • Experience with business process analysis, problem-solving, and process improvement. • Excellent verbal and written communication skills with attention to detail. • Strong critical thinking, decision-making, and adaptability in a changing regulatory environment. • Ability to research, interpret, and implement regulatory guidance effectively. Preferred Skills & Experience: • Prior experience in a compliance or regulatory department. • Certifications such as CHC or CCP are a plus. Education: • Bachelor’s degree in Healthcare Administration, Business, or a related field with strong quantitative and analytical coursework. OpTech is an equal opportunity employer and is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state or local laws. https://www.optechus.com/eeo_self_identification/