JOB DESCRIPTION

Job Summary
Leads and directs team responsible for medical economics analysis activities including extracting, analyzing and synthesizing data from various sources to identify risks and opportunities and improve financial performance. Collaborates with health plans to identify and track savings opportunities. Drives trend performance review process to guide and influence decision-making related to clinical programs, initiatives, and strategy for Medicaid line of business and LTSS / Behavioral Health focus areas.

Essential Job Duties

• Provides oversight for medical economics team and activities ensuring delivery of work/project plans, required reporting, development of savings tracking tools and performance/data management improvement initiatives.
  • Recruits, hires, onboards, mentors, develops, and manages Medical Economics staff.
  • Participates or leads standard trend management review with health plans/shared services to identify performance and trend mitigation opportunities.
  • Coordinates with shared services functions (payment integrity, national contracting, actuarial, etc.) to conduct quarterly deep dive trend reviews and opportunity analyses.
  • Coordinates trend mitigation strategies with health plans and shared services. Leads corresponding savings sizing and tracking processes and performs consistent follow-up on issues and opportunities identified.
  • Ensures core trend tools are maintained to reflect any changes in the business or data structure and coordinates efforts to improve and build on existing tools.
  • Coordinates analytical views of data for oversight of initiatives and impact on trends.
  • Leads team in development of scoreable action item (SAI) tracking tools for savings opportunities in conjunction with SAI leads.
  • Manages intake and prioritization for Medical Economics requests.
  • Coordinates data management advocacy structure and set organizational standards.
  • Acts as primary point of contact between Medical Economics Medicaid trend team and shared services.
  • Stays abreast of professional developments and industry trends

Required Qualifications

• At least 8 years of health care analytics and/or medical economics experience, or equivalent combination of relevant education and experience.
  • At least 3 years management/leadership experience.
  • Bachelor’s degree in statistics, mathematics, economics, computer science, health care management or related field.
  • Advanced understanding of Medicaid and Medicare programs or other health care plans. • Advanced analytical work experience within the health care industry (i.e., hospital, network, ancillary, medical facility, health care vendor, commercial health insurance, large physician practice, managed care organization, etc.) • Advanced proficiency with retrieving specified information from data sources. • Advanced experience with building dashboards in Excel, Power BI, and/or Tableau and data management. • Advanced knowledge of health care operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) • Advanced knowledge of health care financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding/billing (UB04/1500 form). • Advanced understanding of key managed care concepts and provider reimbursement principles such as risk adjustment, capitation, FFS (Fee-for-Service), Diagnosis Related Groups (DRG’s), Ambulatory Patient Groups (APG’s), Ambulatory Payment Classifications (APC’s), and other payment mechanisms. • Advanced understanding of value-based risk arrangements • Advanced experience in quantifying, measuring, and analyzing financial, operational, and/or utilization metrics in health care.