Director of Medical Economics (Revenue)

Advanced Medical Management • US,

9h

About The Position

The Director of Medical Economics (Revenue) leads analysis and optimization of financial performance for a healthcare MSO that owns and operates a Primary Care IPA under full-risk Medicare Advantage contracts. The position focuses on revenue integrity, capitation forecasting, risk score management, and financial performance analysis. It requires deep understanding of value-based care financial models, including Risk Adjustment Factor (RAF), capitation rates, Medical Loss Ratio (MLR), and encounter data reconciliation. The Director provides insights to guide strategic decisions and identify revenue-maximization opportunities for the organization and its provider network.

The role leads forecasting and modeling of capitated revenue, monitors risk-adjustment performance, ensures encounter data and capitation reconciliation, and delivers financial reporting and decision support to executives and external stakeholders. It also supports value-based care strategy, contract negotiations, payor performance meetings, and responses to CMS model changes.

Requirements

• Bachelor’s degree in Finance, Health Economics, Actuarial Science, Public Health, or a related field.
• At least 7 years of experience in medical economics, healthcare finance, or actuarial roles within a payor, MSO, or full-risk IPA.
• Strong knowledge of Medicare Advantage capitation, HCC coding, RAF score management, and MLR.
• Expertise working with large datasets, claims, enrollment files, and encounter data.
• Proficiency in SQL, Excel, Power BI or Tableau, and financial modeling tools.

Nice To Haves

• Master’s degree or MBA.
• Experience in delegated risk-bearing entities with full-risk Medicare Advantage contracts.
• Familiarity with CMS payment methodologies, bid pricing, and trend management.
• Ability to lead and influence cross-functional teams in a matrixed organization.

Responsibilities

• Lead forecasting and modeling of capitated revenue from payors using risk scores, patient attribution, and contract terms.
• Analyze revenue trends, RAF scores, and capitation by plan, region, and provider group.
• Partner with finance and actuarial teams on budget planning and financial reporting.
• Monitor HCC risk score performance and provide strategic input to improve RAF accuracy and completeness.
• Analyze risk-adjustment data, including RAPS, EDPS, and supplemental data, in collaboration with coding and clinical teams.
• Work with Risk Adjustment and Coding departments to evaluate the revenue impact of coding efforts.
• Ensure accuracy of encounter data submissions and completeness of risk-adjustment data feeds from providers.
• Reconcile capitation payments to membership files, enrollment data, and attribution models.
• Identify revenue leakage and drive resolution through audits and systemic fixes.
• Provide insights and performance reporting to executive leadership, the board, and external stakeholders.
• Support value-based care strategy, contract negotiations, and payor performance meetings with financial analysis.
• Analyze the impact of CMS model changes, such as HCC V28, and support transition strategies.

Benefits

• Full employer-paid HMO coverage and an optional flexible PPO plan.
• Discounted vision and dental premiums.
• Flexible spending accounts for healthcare and dependent care costs.
• 401(k).
• Generous paid time off.
• 40 hours of sick pay.
• 13 paid holidays.
• Tuition reimbursement.
• Paid company outings and lunches.

What This Job Offers

• Job Type: Full-time
• Career Level: Director