VP, Medical Economics

Job Summary

Provides executive level strategy and leadership for 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 and outcomes. Collaborates with health plans to develop scoreable action item (SAI) tracking tools and identify opportunities to improve performance and data management, and support, guide and influence decision-making related to clinical programs, initiatives and strategy.

Essential Job Duties

• Regularly unpacks detailed medical cost information to identify significant trends development and underlying causes of those trends.
• Supports executive strategy development, vision and direction for the enterprise medical economics function including SAI analytics, governance and trend mitigation. Demonstrates accountability for performance and financial results, and keeps executive leadership apprised.
• Recruits, hires, onboards, mentors, develops, and manages a team of medical economics team of professionals.
• Collaborates with senior level clinicians and leaders from functional areas such as finance, health care services and provider contracting to translate analytic observations into meaningful clinical / operational actions and management of clinical services to support, guide and influence decision making related to clinical programs, initiatives and strategy.
• Leveraging targeted analytics, works with business leaders to develop programs to support affordable, high quality health care delivery.
• Identifies gaps in critical information and works with business leaders to develop solutions to capture or supplement information required.
• Informs and supports regular forecasting activities of the enterprise.
• Propagates best medical economics / analysis / SAI development practices across the enterprise.
• Leads enterprise information management (EIM) team to build out data analytic tools and capabilities.
• Develops standards with regard to routine health care economics analyses, including types of analyses performed, frequency by health plan or line of business, etc.

Required Qualifications

At least 12 years of health care analytics and / or medical economics experience, including 3 years of experience at an executive level, or equivalent combination of relevant education and experience. At least 7 years management / leadership experience. Bachelor's degree in statistics, mathematics, economics, computer science, health care management or related field. Extensive experience in a leadership position in health care economics, preferably with complex organizations. Ability to effectively communicate and persuade technical and non-technical stakeholders, and engage with various levels within the organization Demonstrated ability to work with sophisticated analytic tools and datasets. Demonstrated ability to convert observations into actions / interventions to improve financial performance. 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 understanding health care operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) Advanced understanding on 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. Advanced problem-solving skills. Strong critical-thinking and attention to detail. Excellent verbal and written communication skills. Proficient in Microsoft Office suite products, advanced skills in Excel (VLOOKUPs and pivot tables) / applicable software program(s) proficiency.

Preferred Qualifications

Experience in complex managed care. Associate of the Society of Actuaries (ASA) or Fellow of the Society of Actuaries (FSA).