Cost of Care, Manager

The Manager, Total Cost of Care, will monitor financial performance and provide analytic insights into all products offered within the Healthfirst portfolio. This leader will serve as healthcare economics and analytics subject matter expert, across all areas of medical trend, medical cost savings, provider network informatics, and reimbursement accuracy. The ideal candidate will come from a managed care, medical economics, insurance, actuarial, or hospital background, and will be a results-oriented individual who enjoys working in a fast-paced and challenging environment.

• Monitor medical cost and utilization trends, provide concise actionable insight into the root cause drivers, and develop potential remediation opportunities.
• Develop savings analyses for Medical Economics cost trend reduction initiatives, applying financial modeling expertise and using independent judgement to determine best valuation methods.
• Prioritization of cost mitigation activities across business areas.
• Provide actionable data driven analysis to Finance, Claims, Pharmacy, Payment Integrity, Medical Management, Network, and other departments to enable critical decision making.
• Optimize contractual reimbursement terms and coding across agreements, systematically identifying reimbursement outliers. Assess and work with Network to standardize contractual terms and language across all provider agreements.
• Evaluate data to identify and root cause of payment integrity issues and lead cross-functional efforts to problem solve.
• Lead development of tools and processes for efficient operational and reimbursement management of hospitals and physician partners, including unit cost projections.
• Develop interactive financial models to evaluate the impact of provider reimbursement changes.
• Support all provider settlement and data reconciliation activities.
• Development of tools to define profitability dashboards by product.
• Keep abreast of New York Medicaid and Medicare reforms, reimbursement methodologies, and their impact on Healthfirst and their owner hospital performance.
• Individual contributor subject matter expert and/or managerial responsibilities.
• Perform ad hoc analyses.

• Bachelor’s Degree from an accredited institution.
• Must be able to work a hybrid work schedule consisting of reporting to our 100 Church Street, NYC office on Tuesdays, Wednesdays & Thursdays.
• At least six (6) years of healthcare analytics experience, with at least three (3) years of experience in contract evaluation, medical economics, medical cost containment, actuarial , healthcare reimbursement model design.
• Extensive knowledge of managed care financial metrics (PMPM, util/k, cost/unit).
• Experience utilizing healthcare claims data to uncover valuable insights to improve financial performance.
• Experience with Government and proprietary payor reimbursement methodologies and unit cost management.
• Experience with SAS or SQL (creates queries and manipulation of data).
• Extensive experience with Microsoft Excel (building financial models, utilizing pivot tables, vlookups, index match, and calculated fields).
• Claims experience including root-cause analysis, system set-up, etc
• Ability to work with large data sets.
• Strong written and verbal communication skills.
• Experienced in leading a team of analysts.
• Resourceful and creative in solving complex issues and working corroboratively with others on a solution.
• Ability to manage projects and project plans within stated timelines.

• Expertise in 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…