Director, Healthcare Economics (Medicare)

Clever Care Health Plan•Huntington Beach, CA

4d•$140,800 - $193,525•Hybrid

About The Position

The Director, Healthcare Economics is responsible for leading healthcare economics analytics, Clinical Affordability initiatives, and Population Health analytic support that advance Clever Care Health Plan’s financial performance, quality outcomes, member health outcomes, and value-based care strategy. This role serves as a hybrid of hands-on analytics leader and strategic business partner, translating complex claims, membership, pharmacy, risk adjustment, Stars, network contracting, value-based care, and population health data into clear insights, executive-ready recommendations, and measurable actions. The Director will lead the analytical portion of the Clinical Value Committee meeting, manage a team of analysts within the Healthcare Economics team, and partner cross-functionally with Clinical, Finance, Risk Adjustment, Stars/Quality, Pharmacy, Network, Operations, Product, IT, and external partners. This role requires strong technical analytics capability, strategic thinking, executive communication, and the ability to connect cost-of-care drivers to practical business and clinical interventions.

Requirements

Bachelor’s degree in Healthcare Administration, Finance, Economics, Actuarial Science, Statistics, Data Analytics, Public Health, Business, or related field; master’s degree preferred.
7–10 years of progressive experience in health care analytics, healthcare economics, actuarial support, financial analytics, or managed care analytics.
Medicare Advantage or managed care experience strongly preferred.
Experience analyzing claims, membership, pharmacy, utilization, risk adjustment, Stars/quality, provider contracting, or value-based care performance.
Experience supporting population health analytics, chronic condition cohort development, risk stratification, or targeted clinical program evaluation preferred.
Experience leading cross-functional analytics initiatives and translating findings into operational or strategic recommendations.
Prior experience managing analysts or analytics teams preferred.
Strong analytical, quantitative, and critical thinking skills with the ability to synthesize complex healthcare data into clear conclusions and recommendations.
Hands-on experience with SQL, Excel, Power BI, claims data, MMR, EDS, ACG, and other healthcare data sources or analytics platforms.
Strong understanding of Medicare Advantage economics, cost-of-care drivers, utilization trends, risk adjustment, Stars, pharmacy trends, provider reimbursement, and value-based care concepts.
Knowledge of population health concepts, including risk stratification, chronic condition prevalence, care gap identification, high-risk member targeting, avoidable utilization, and program outcome measurement.
Ability to create practical Population Health deliverables such as member segmentation files, chronic condition cohort definitions, disease burden summaries, intervention opportunity lists, outreach prioritization reports, and program outcome dashboards.
Ability to develop executive-ready presentations, dashboards, scorecards, and business cases that support strategic decision-making.
Excellent communication and presentation skills with the ability to engage senior leaders and cross-functional stakeholders.
Strong project management, prioritization, and organizational skills with ability to manage multiple initiatives concurrently.
Collaborative leadership style with ability to coach analysts, influence without direct authority, and drive accountability across teams.
High attention to detail, data integrity, confidentiality, and compliance requirements.

Nice To Haves

Master's degree preferred.
Experience supporting population health analytics, chronic condition cohort development, risk stratification, or targeted clinical program evaluation preferred.
Prior experience managing analysts or analytics teams preferred.

Responsibilities

Provide strategic leadership and governance for the Clinical Affordability forum, setting its priorities and decision agenda, aligning cross-functional stakeholders around the highest-impact affordability opportunities, directing the development of executive-ready analyses and recommendations, and ensuring disciplined follow-through on decisions and accountabilities.
Develop and manage healthcare economics analyses related to claims trend, membership analytics, utilization, unit cost, mix, pharmacy spend, risk adjustment financial performance, Stars analytics, network contracting, and value-based care performance.
Translate complex data into clear business narratives, identifying cost-of-care drivers, emerging risks, margin opportunities, and recommended actions for senior leadership.
Partner with Population Health, Quality, and Clinical leadership to evaluate program performance, identify high-risk member cohorts, measure care management impact, and recommend opportunities to improve affordability and outcomes.
Develop reporting packages that summarize member morbidity burden, chronic condition trends, utilization patterns, pharmacy indicators, care management engagement, and outcomes performance for leadership review and program planning.
Support the Population Health function by developing analytics that identify priority populations, stratify members by risk and opportunity, and inform targeted interventions for chronic condition management, care gaps, utilization reduction, and improved health outcomes.
Partner with Population Health, Quality, and Clinical leaders to evaluate member cohorts, program engagement, outcomes, and return on investment for initiatives designed to improve health status and reduce avoidable utilization.
Evaluate and ensure the continued effectiveness of culturally sensitive care models and culturally attuned benefits, including benefits such as acupuncture, herbal medicine, language-concordant engagement, community-based supports, and other culturally relevant interventions, by measuring utilization, member engagement, outcomes, satisfaction, avoidable utilization, and financial impact.
Support Risk Adjustment and Stars/Quality teams with financial analytics, performance tracking, and insight generation related to RAF, documentation, quality outcomes, and Stars measures.
Collaborate with Pharmacy, Network, Finance, Operations, Product, IT, and external vendors to integrate data and develop a unified view of medical cost performance and intervention opportunities.
Evaluate program effectiveness using cost impact, trend reduction, utilization changes, ROI, scalability, and operational feasibility.
Develop repeatable reporting frameworks, dashboards, scorecards, and methodologies that improve consistency, accuracy, and timeliness of Healthcare Economics deliverables.
Ensure key metrics such as PMPM, utilization, unit cost, membership mix, risk scores, pharmacy trends, and quality-related performance indicators are clearly defined, consistently reported, and actionable.
Provide leadership and direction to team of analysts, including prioritization of work, review of analytical outputs, coaching on business context, and development of executive communication skills.
Identify process improvements, data quality issues, and reporting enhancements that strengthen decision-making and departmental efficiency.
Maintain compliance with Clever Care Health Plan corporate and departmental policies and procedures, including but not limited to Employee Code of Conduct, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications, and Quality Management Accountabilities.
Perform other duties as assigned.