Business Analytics, Senior Analyst

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.

Position Summary

The Data Analyst for claims & reporting is responsible for overseeing Medicaid claims operations, inventory management, quality assurance, and compliance monitoring. This role ensures timely and accurate processing of Medicaid claims in accordance with state and federal regulations, contractual requirements, and organizational performance standards.

Key Responsibilities

• Manage daily Maryland Medicaid claims pend buckets to ensure timely and accurate claims adjudication and payment.
• Oversee inventory levels, turnaround times (TAT), backlog reduction, reduction of claims interest, suspended claims work queues, and provider dispute resolution.
• Drive improvements in auto-adjudication rates, accuracy, and first-pass resolution.

• Ensure all claims processes comply with:
  • State Medicaid regulations and billing guidelines
  • CMS requirements and Federal managed care rules
  • Timely filing laws and encounter data reporting requirements
• Support readiness reviews, audits, Corrective Action Plans (CAPs), and state submissions.

• Implement QA programs to monitor claim accuracy, provider payment integrity, and policy adherence.
• Review and analyze claims performance dashboards, error trends, and key metrics (TAT, payment accuracy, denial rates, encounters, etc.).
• Partner with Finance on claims reserves, cost-of-care reporting, and reconciliation issues.

• Work closely with Configuration, Cotiviti and Claim Xten to resolve system issues, benefit configuration errors, and pricing or editing defects.
• Partner with Provider Relations to address contractual interpretation questions and recurring provider submission issues.
• Collaborate with Utilization Management/Medical Management on authorization-related claims issues.
• Coordinate with Compliance and Legal on regulatory changes and required process updates.

• Lead initiatives to streamline workflows, automate processes, reduce manual interventions, and improve accuracy.
• Drive root-cause analysis and implement sustainable corrective actions.
• Participate in the development of policy and procedure updates for Medicaid claims operations.

Required Qualifications

• Bachelor’s degree in Business, Healthcare Administration, or related field.
• 3+ years of claims experience in Medicaid.
• Strong understanding of Medicaid billing rules, HSCRC, provider types, benefit structures, and encounter reporting.
• Experience with major claims systems (e.g., QNXT).
• Problem solving mindset; adaptable, ability to analyze processes.
• Analytical skills with proficiency in Excel and claims data analysis.
• Job responsibilities are not limited to the description above.

Preferred Qualifications

• Experience with Medicaid managed care organizations (MCOs) or state Medicaid agencies.
• Knowledge of fee schedules, and Medicaid pricing methodologies.
• Background in payment integrity, claims audits, configuration testing, or encounter operations.

Education
Bachelor’s degree in Business, Healthcare Administration, or related field.

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$46,988.00 - $112,200.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.

Additional details about available benefits are provided during the application process and on Benefits Moments.

We anticipate the application window for this opening will close on: 04/28/2026

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.