Manager, Medical Economics (New York Health Plan)

Manager, Medical Economics

The Manager, Medical Economics provides support and consultation to the New York Health Plan and Finance team through analyzing key business issues related to cost, utilization and revenue for multiple Molina Healthcare products. Analyzes data and dashboard reports to monitor health plan performance and identify the root causes of medical cost trends. With those root causes identified, drives improvement change by recommending actionable initiatives to C-level executives to mitigate these trends. Responsible for conducting complex analyses of insured medical populations with the goal of identifying opportunities to improve financial performance. Extracts, analyzes, and synthesizes data from various sources to identify risks and opportunities.

Manages and provides direct oversight of Medical Economics Team activities and personnel. Provides technical expertise, manages relationships with operational leaders and staff. Directs staff assigned to their projects, supports health plan market(s) with trend analyses, finding scoreable action items (SAIs) and ad hoc analyses as requested. Responsible for staff time keeping, performance coaching, development, and career paths.

Extract and compile information from various systems to support executive decision-making. Mine and manage information from large data sources. Analyze claims and other data sources to identify early signs of trends or other issues related to medical care costs. Work with clinical, provider network and other personnel to bring supplemental context / insight to data analyses, and design and perform studies related to the quantification of medical interventions. Work with business owners to track key performance indicators of medical interventions. Perform pro forma sensitivity analyses in order to estimate the expected financial value of proposed medical cost improvement initiatives. Proactively identify and investigate complex suspect areas regarding medical cost issues, initiate in-depth analysis of the suspect / problem areas, and suggest a corrective action plan. Draw actionable conclusions based on analyses performed, make recommendations through use of healthcare analytics, predictive modeling, and communicate those conclusions effectively to audiences at various levels of the enterprise. Analyze the financial performance of all Molina Healthcare products, identify favorable and unfavorable trends, develop recommendations to improve trends, communicate recommendations to management. Lead projects to completion by contributing to ad-hoc data analyses, development, and presentation of financial reports. Serve as subject matter expert on developing financial models to evaluate the impact of provider reimbursement changes. Provide data driven analytics to Finance, Claims, Medical Management, Network, and other departments to enable critical decision making. Support Financial Analysis projects related to medical cost reduction initiatives and budgeting same. Support Medical Management by assisting with Return on Investment (ROI) analyses for vendors to determine if their financial and clinical performance is achieving desired results. Keep abreast of Medicaid and Medicare reforms and their impact on Molina Healthcare.

Required Education : Bachelor's Degree in Finance, Economics, Math, Healthcare Management, Computer Science, Information Systems, or related field.

Required Experience : + 3 years management or team leadership experience + 10 years analytical work experience within the healthcare industry + Strong Knowledge of SQL and PowerBI report development + Familiar with relational database concepts, and SDLC concepts.

Preferred Education : Masters' Degree in Finance, Economics, Math, Computer Science, Information Systems, or related field.

Preferred Experience : + 3 5 years supervisory experience + Demonstrated understanding of Medicaid and Medicare programs or other healthcare plans + Experience with Databricks + Proficiency with Microsoft Excel (formulas, PIVOT tables, PowerQuery, etc.) + Proficiency with Excel and SQL for retrieving specified information from data sources. + Knowledge of healthcare operations (utilization management, disease management, HEDIS quality measures, claims processing, etc.) + Knowledge of healthcare financial terms (e.g., PMPM, revenue) and different standard code systems (ICD-10CM, CPT, HCPCS, NDC, etc.) utilized in medical coding / billing (UB04 / 1500 form) + Demonstrated understanding of 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 Classifications (APC's), and other payment mechanisms. Understanding of value-based risk arrangements + Experience in quantifying, measuring, and analyzing financial, operational, and / or utilization metrics in healthcare.