The Director Medical Economics develops and manages a high-performing team, provides leadership in managing overall medical costs, regional medical cost action plans, and designs metrics for business partners that are accountable for implementation of action plans. Responsible for building expertise in provider contracting by leading the design, development, and distribution of database tools and applications to efficiently measure monitor, and/or forecast medical cost structure. Develops and presents actionable recommendations for utilization and unit cost management to business partners based on analysis. Partners with actuarial, underwriting, network, clinical and operations leaders to establish implementation strategy of action items.
Key Outcomes: Partners with line of business product leaders and Informatics to develop and design medical economics analysis and outcomes reporting to be used for internal and external purposes Supports month end analysis, budget and forecast development, and medical expense projections Supports the development of medical expense management initiatives inclusive of cost saving projections and offsets in partnership with internal and external stakeholders Collects and refines appropriate data for analysis, provides summations, observations and insights to address utilization trends and presents findings to management and other stakeholders (internal and external) Participates in strategic discussions regarding medical cost, utilization, contracting and care collaboration, and network programs Utilizes data and analytic information available to drive decisions, and evaluates impact, effectiveness, performance and cost Partners with Network Management leadership to develop analysis of provider cost and quality performance, identify opportunities for improvement, and propose changes to the reimbursement models, risk arrangements, etc. Collaborates with leadership and Provider Relations team to provide comprehensive reports, deliverables and presentations Leads medical expense work groups consisting of an interdisciplinary team of individuals from across the Health Plan Collaborates with the Finance and Health Management teams to support financial analyses such as Net Present Value (NPV) and performance analyses to evaluate the effectiveness and return on investment (ROI) of clinical programs Integrates pharmacy and medical data components in support of medical expense Coordinates, manages and tracks performance standards and reporting by developing effective tools that measure progress and the achievement of milestones Provides very complex programming and analytical support for medical cost trend analysis and strategic planning Creates population-based medical cost analyses from concept to completion Analyzes historical provider trends and experience to support the Company's move to alternative payment methodologies Trains team members on analytical tools and techniques
Education/Experience: Bachelor’s degree in business, health administration, health policy, finance or a related field required; Master’s degree preferred 5+ years of experience in managed care analytics and risk management, Medicare Advantage programs, Medicare payment practices and policies, managed care finance, network contracting, and clinical program cost-effectiveness analytics required Experience working with pricing and other key financial departments required Leadership experience is preferred Solid knowledge of standard medical coding preferred In compliance with MPHC's Department of Defense government contract, any/all persons hired for this position will need to verify their US citizenship and complete the required employment eligibility verification upon hire.
We are an equal opportunity/affirmative action employer.