Medical Economist

Devoted Health • Waltham, MA

22d • $175,000 - $250,000 • Remote

About The Position

The Medical Economist is a strategic and operational leader responsible for optimizing medical cost management, driving total cost of care strategy, and improving financial performance across Commercial lines of business. The role connects financial strategy with operational execution by evaluating provider reimbursement models, working with technical and claims teams to support accurate system configuration and adjudication, monitoring medical expense trends, and providing actionable intelligence to executive leadership. Proven practical experience, problem-solving ability, and operational impact are emphasized over formal education or credentials.

The role partners with Network Development and Contracting teams to design and evaluate provider reimbursement structures, model financial impacts before contracts are executed, and oversee the financial mechanics of Commercial value-based arrangements. It also works with Claims, Health Plan Operations, Engineering/IT, and Payment Integrity to translate contract terms into technical specifications, validate claims adjudication, identify payment defects and cost leakage, and lead remediation.

The Medical Economist monitors and decomposes Commercial Total Medical Expense across care categories, synthesizes clinical, claims, authorization, and financial data into business intelligence, and benchmarks costs against Medicare rates and regional commercial benchmarks. The role also analyzes Commercial cost drivers, supports forecasting and reserve estimates with Actuarial, Finance, and Underwriting teams, evaluates the financial impact of clinical and care management initiatives, and presents financial trends and strategic recommendations to executives and cross-functional leaders.

Requirements

• At least 8 years of progressive hands-on experience in healthcare economics, managed care finance, or healthcare data analytics.
• At least 3–5 years of experience focused specifically on Commercial lines of business, such as Individual/ACA, Group, or ASO/Self-Funded.
• Deep practical knowledge of Commercial reimbursement methodologies, including Commercial fee-for-service schedules, Medicare-relative pricing, DRGs, CPT/HCPCS, Revenue Codes, APCs, ASC fee schedules, stop-loss, and Commercial risk adjustment.
• Demonstrated experience evaluating provider contract language, modeling reimbursement shifts, and collaborating with IT and claims teams to guide configuration and ensure accurate claims adjudication.
• Hands-on ability to query, manipulate, and analyze large healthcare claims datasets using SQL, Python, R, SAS, or modern cloud data warehouses.
• Proven ability to lead cross-functional initiatives and align priorities across Network, Claims, Operations, Engineering, Finance, and Actuarial teams.
• Strong ability to explain complex claims and financial data in plain language and present actionable recommendations to executive leaders.

Nice To Haves

• Direct experience designing, evaluating, or managing Commercial ACO models, bundled payment structures, and shared risk or savings arrangements.
• Practical understanding of Commercial regulatory environments, including state insurance mandates, ACA guidelines, ERISA, and the No Surprises Act.
• Experience working in health plan operations, health systems, or provider organizations and navigating managed care contracts.
• Actuarial credentials such as ASA or FSA, or an advanced degree such as a Master’s or MBA; these are optional and not required when relevant practical experience is demonstrated.

Responsibilities

• Partner with Network Development and Contracting teams to design, model, and evaluate provider reimbursement structures across Commercial networks.
• Conduct pre-contract modeling and scenario analysis for fee schedules, tiering, facility contracts, and alternative payment models.
• Oversee financial mechanics for Commercial value-based contracts, shared savings and risk arrangements, quality bonus pools, and provider incentive programs.
• Translate contract terms, fee schedules, and payment logic into technical specifications in collaboration with Claims, Health Plan Operations, and Engineering/IT teams.
• Establish testing, audit, and validation frameworks to ensure claims adjudicate according to contracted intent and configuration design.
• Identify claim adjudication defects, configuration errors, and unexpected cost leakage; lead root-cause analysis and system remediation.
• Monitor and report Total Medical Expense, distinguishing price, utilization, mix shifts, and intensity across inpatient, outpatient, professional, and pharmacy categories.
• Synthesize clinical, claims, authorization, and financial data to identify medical cost drivers and cost-optimization initiatives.
• Perform competitive market benchmarks to identify fee schedule gaps, contracting leverage, and efficiency opportunities.
• Analyze Commercial cost drivers, including high-cost claimant spikes, ACA risk adjustment, stop-loss and reinsurance recoveries, benefit design changes, and out-of-network leakage.
• Partner with Actuarial, Finance, and Underwriting teams on medical loss ratio forecasting, IBNR reserve estimates, premium rate-setting, and employer group performance reporting.
• Collaborate with Clinical Operations and Medical Management to evaluate the ROI and medical cost impact of disease management, utilization management, and population health initiatives.
• Prepare and deliver executive summaries, monthly and quarterly financial trend packages, and strategic recommendations to market leadership, the CFO, and cross-functional steering committees.

Benefits

• Employer-sponsored health, dental, and vision plans with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for roles below Director level; commission eligibility for Sales roles
• Parental leave program
• 401K program

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed