Medical Economics Analyst

Summary

The Medical Economics Analyst supports all healthcare analytical efforts of the fast-growing company’s various value-based contracts. This position will use electronic health record, and various payer portals and reports to gather, analyze, and present actionable solutions to complex healthcare issues. The analysis will range from macro healthcare cost and/or trends and individual patient analysis. The position works on multiple projects as a subject matter expert in a fast-paced environment for the support of executive management, physicians and other internal or external clients. Obtains, understands, and communicates reporting specifications from government agencies and other entities.

Duties and Responsibilities

1. Report and present medical cost and utilization.
2. Analyze and report member enrollment history, medical claims based on diagnosis and procedures based on assigned tasks.
3. Trace enrollment source based on established procedures and criteria.
4. Research root cause for high claims cost based on medical coding, provider type, place of service and other criteria.
5. Communicate with leadership regarding receipt of kick-payments and stop loss recoveries. Follow up with stop loss vendors to assure that they have access to necessary administrative information to process credits.
6. Test and validate impact of all updates prior to incorporating assumptions into expected reimbursement calculations.
7. Provide support and collaborate with the department to develop best practices for identifying, trending, quantifying and escalating discrepancies from clinical data.
8. Managed Care and Business Analytic Reporting: design, create and maintain departmental managed care monitoring and analytic reports; conduct searches for relevant internal and external data sources that would be appropriate for enhancing analytics; research and incorporate best practices for data visualization methods and techniques.
9. Maintain a high level of quality, accuracy, and process consistency. Responsible for efficient distribution of reports and other intelligence essential to management and the organization.
10. Work closely with the Manager to develop and analyze reporting and clinical data, providing profitability analyses and insights to customer proposals.
11. Create proactive analyses comparing company or market results to industry data to evaluate program performance for internal management and internal clients.
12. Develop and produce financial reports and clinical analysis on a periodic and ad-hoc basis for care coordination staff as well as physicians and executive leadership.
13. Ensures accuracy and timeliness of the company’s staff and physician reports to include regularly scheduled and ad-hoc reporting requests. Responsible for all follow-up and/or research requests regarding physician data.
14. Participates in project teams, analyzing various new programs, projects, or ventures that require analysis of clinical, financial, or utilization data.
15. Prepares reports, presentations, and other documents and presents these materials in meetings.
16. Identify problematic areas and conduct research to determine the best course of action to correct the data.
17. Participates in high-level business initiatives and assist with all levels of metric reporting.
18. Maintains a working knowledge of relevant Government, payor, and third-party health care initiatives in which the company participates. It is assumed, in order to maintain these skills, that relevant seminars, books, periodicals and regulations be routinely reviewed.
19. Interpret data and provide business insights, understandable to non-technical users, and communicating key findings.
20. Keep track of capitated specialties looking for leakage, cost increases, carve outs procedure, and any other critical changes that affect cost/savings.
21. Analyzes medical encounters, revenue cycle based on LOB, MLR for costs/savings opportunities.
22. Perform other duties as assigned.

Qualifications

Education/Experience:

1. Bachelor’s in Business Administration, Healthcare Administration or related field required
2. MBA, MPH, MHA, or advanced degree in a related area preferred
3. 2+ years experience in healthcare, insurance, consulting, or data analytics; an understanding of Electronic Medical records and population management systems strongly preferred
4. Experience in healthcare and/or value-based modeling, including Medicare Advantage, Medicare Shared Savings Program (MSSP), payor risk models, is a plus
5. Utilization of data analytics or visualization tools (e.g., Excel, SQL, SAS, Tableau, Statistical Modeling)