Apcd Jobs (NOW HIRING)

Who We Are
Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.
We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.
Job Summary
Under the supervision of a Manager for Reporting and Analytics, Government Programs, the Senior Data Analyst leads critical data submission activities for the Risk Adjustment Department (RAD). This role is accountable for the completeness, accuracy, and timeliness of Point32Health's All-Payer Claims Database (APCD) submissions across applicable markets, as well as supporting the encounter data submissions to Rhode Island EOHHS.
The analyst oversees internal data reconciliations, manages data exchanges with external partners, and supports regulatory reporting requirements. Serving as the primary point of contact for APCD-related initiatives and supporting RI-EOHHS encounter submissions, the role collaborates with internal teams, external stakeholders, and state agencies to ensure compliance and operational excellence.
The ideal candidate demonstrates strong analytical and critical-thinking skills, with the ability to independently analyze large and complex datasets, assess data quality, identify trends and root causes, and translate findings into clear insights for leadership. Advanced SQL proficiency is required, and healthcare data knowledge is strongly preferred.
Job Description
DUTIES/RESPONSIBILITIES - what you will be doing:
Data Management and Production:

• Independently manage and execute monthly APCD data submissions to state agencies for Tufts Health Plan and Harvard Pilgrim Health Care commercial and government products.
• Support RI EOHHS encounter data submissions, including error analysis, reconciliation, remediation, and end-to-end submission support.
• Ensure compliance with regulatory requirements, business rules, data standards, and technical specifications; document requirements and data logic as needed.
• Monitor and analyze encounter and APCD response files to identify rejections, discrepancies, and data quality issues; perform trend analysis and root-cause investigations and drive timely resolution.
• Lead prioritized data remediation efforts for encounter and APCD defects in collaboration with business and technical partners.
• Develop, enhance, and automate reconciliation and reporting processes using SQL, SAS, Alteryx, and/or other analytical tools.
• Partner with IT and data engineering teams on enhancements and production issue resolution, including requirements clarification, issue investigation, UAT, and post-implementation validation.
• Support encounter and APCD data readiness for risk adjustment, financial reconciliation, actuarial reporting, and regulatory audits.
• Serve as a subject-matter expert for encounter and APCD data submission logic, providing guidance and recommendations to cross-functional teams.

Change Management and Process Improvement:

• Lead change management efforts related to state-issued specifications and internal enhancements impacting encounter and APCD data submissions.
• Perform end-to-end issue analysis, including root-cause identification, documentation of business requirements, implementation of data or process changes, user acceptance testing (UAT), and post-implementation monitoring.
• Identify inefficiencies and improvement opportunities in monthly data submission, reconciliation, and tracking processes, and drive continuous improvement initiatives.
• Monitor the effectiveness of implemented changes, make necessary adjustments, and ensure sustained regulatory compliance and operational stability.
• Develop and maintain submission dashboards and reconciliation reports using Tableau, Excel, and other reporting tools to track acceptance rates, trends, and performance metrics.

Collaboration and Stakeholder Management:

• Collaborate closely within the Risk Adjustment department and with cross-functional partners including Claims, Member Operations, Information Technology, and Provider Information to ensure data submission processes and enhancements are effectively implemented and maintained.
• Partner with IT to support timely resolution of production issues, ensuring alignment between business requirements and technical solutions.
• Engage with external stakeholders, including state agencies, their consultants, vendor data management teams, and industry trade associations, to stay informed of regulatory updates, policy changes, and evolving submission requirements.
• Communicate findings, risks, and recommendations clearly to management and stakeholders to support informed decision-making.

Administration:

• Attend internal and external (state-led) meetings; document key decisions; and track and manage follow-up actions through completion.
• Develop, maintain, and update business policies, procedures, and knowledge repositories to support consistent operations, effective onboarding, and audit readiness.

QUALIFICATIONS - what you need to perform the job
Education

• Required: Bachelor's degree required; master's degree preferred.
• Bachelor's degree in health informatics, information technology, data management, or a related discipline.

Experience

• Required: 5-7 years of experience in progressively responsible analytical and data management roles.
• Prior experience in the healthcare or health insurance sector (e.g., health plan, provider group, healthcare IT, or auditing firm), and/or experience working with large datasets in a technical capacity.
• Experience developing, maintaining, and updating detailed policies and procedure documentation.
• Understanding of claims systems, provider data, and Medicaid, Medicare, and commercial products preferred.
• Prior experience with regulatory data submissions, including All-Payer Claims Database (APCD) submissions, a plus.

Skill Requirements

• Expertise in data management and controls, IT processes, and analytical tools; comfortable working with large datasets from disparate sources and identifying meaningful patterns and trends.
• Advanced technical skills in SQL and proficiency in Microsoft Excel.
• Experience with database systems such as Teradata and Oracle
• Experience with SAS, Alteryx, Databricks, Tableau, and knowledge of X12 837, 277, and 835 EDI transactions a plus.
• Demonstrated ability to manage multiple projects simultaneously in a complex, fast-paced environment.
• Demonstrated maturity and professionalism, with the ability to navigate complexity, ambiguity, and incomplete information.
• Engaged, critical thinker who is organized, detail-oriented, resourceful, and self-motivated; able to work independently and collaboratively.
• Strong verbal, written, and interpersonal communication skills, with the ability to influence without authority and work effectively with internal and external stakeholders.
• Team-oriented, resilient, flexible, and committed to high-quality processes and outcomes.
• Ability to quickly learn and adapt to new technologies and applications.

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 standard office conditions and from home as required.
• The role may require simultaneous use of a telephone or headset and a PC/keyboard, as well as sitting for extended periods of time.
• 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 the standard work schedule, as business needs dictate.

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
$88,942.17 -$133,413.25
Compensation & Total Rewards Overview
The 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/
We welcome all
All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
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