Manager, Total Cost of Care

HealthFirst•New York, NY

7d•$88,700 - $149,430

About The Position

The Manager, Total Cost of Care monitors financial performance and provides analytic insights across all products in the Healthfirst portfolio. This leader serves as a healthcare economics and analytics subject matter expert in medical trend, medical cost savings, provider network informatics, and reimbursement accuracy. The role calls for a results-oriented professional who can work in a fast-paced and challenging environment. It includes individual-contributor subject matter expertise and/or managerial responsibilities, as well as ad hoc analysis.

Requirements

Bachelor’s degree from an accredited institution.
At least six years of healthcare analytics experience, including at least three years in contract evaluation, medical economics, medical cost containment, actuarial work, or healthcare reimbursement model design.
Extensive knowledge of managed-care financial metrics, including PMPM, utilization per thousand, and cost per unit.
Experience using healthcare claims data to uncover insights that improve financial performance.
Experience with government and proprietary payer reimbursement methodologies and unit-cost management.
Experience with SAS or SQL, including creating queries and manipulating data.
Extensive Microsoft Excel experience, including building financial models and using pivot tables, VLOOKUPs, INDEX/MATCH, and calculated fields.
Claims experience, including root-cause analysis and system setup.
Ability to work with large data sets.
Strong written and verbal communication skills.
Experience leading a team of analysts.
Resourcefulness and creativity in solving complex issues and collaborating with others on solutions.
Ability to manage projects and project plans within stated timelines.

Nice To Haves

Expertise in managed-care concepts and provider reimbursement principles such as risk adjustment, capitation, fee-for-service, Diagnosis Related Groups (DRGs), Ambulatory Patient Groups (APGs), Ambulatory Payment Classifications (APCs), and other payment mechanisms.
Understanding of value-based risk arrangements.
Experience using Tableau and Python.
Experience mentoring other team members.

Responsibilities

Monitor medical cost and utilization trends, explain root-cause drivers with concise, actionable insights, and develop potential remediation opportunities.
Develop savings analyses for Medical Economics cost-trend reduction initiatives, applying financial modeling expertise and independent judgment to select valuation methods.
Prioritize cost-mitigation activities across business areas.
Provide data-driven analysis to Finance, Claims, Pharmacy, Payment Integrity, Medical Management, Network, and other departments to support critical decisions.
Optimize contractual reimbursement terms and coding across agreements, identify reimbursement outliers, and work with Network to standardize contractual terms and language across provider agreements.
Evaluate data to identify and determine root causes of payment-integrity issues, and lead cross-functional problem-solving efforts.
Lead development of tools and processes for efficient operational and reimbursement management of hospital and physician partners, including unit-cost projections.
Develop interactive financial models to evaluate the impact of provider reimbursement changes.
Support provider settlement and data reconciliation activities.
Develop tools to define profitability dashboards by product.
Keep abreast of New York Medicaid and Medicare reforms and reimbursement methodologies, and assess their impact on Healthfirst and owner-hospital performance.
Perform ad hoc analyses.