DescriptionJob Summary:The Health Care Economist shows leadership where Pathways' money and outcomes are actually going. Using Pathways' CMS Claim and Claim Line Feed (CCLF) files and related CMS reports, the position projects how the ACO makes or loses money at every level: across the whole ACO, by participant and provider, and down to the individual patient and each episode of care. The position analyzes claims, cost, and utilization data; builds and maintains the financial models behind our value-based care arrangements (ACO REACH, LEAD, and Medicare Advantage); and turns that analysis into decisions leadership can act on - from how we structure contracts to which care interventions are worth scaling. This is a working leader role: the Health Care Economist owns the decisions that come from their work, not a report that sits on a shelf.
Role and Responsibilities Position Competencies:
1. Applies statistical and econometric methods to imperfect, real-world data and draws defensible conclusions from it.
2. Understands CMS claims data structures (CCLF), including claim adjustments, cancellations, and run-out, and can reconcile internal results to CMS reports.
3. Understands Medicare payment models, CMS ACO benchmark and shared savings/loss methodology, and CMS-HCC risk adjustment.
4. Explains technical findings in plain English to non-technical audiences, in writing and in person.
5. Knows and maintains professional communication skills: verbal, written, and non-verbal communication.
6. Understands and maintains the highest level of HIPAA (Health Insurance Portability and Accountability Act) standards.
Qualifications/Position Requirements:
1. Education: Master's degree or Ph.D. in health economics, economics, health policy, public health, statistics, or a related quantitative field.
2. Experience: Minimum of 3 years analyzing health care cost and utilization data in a payer, provider, ACO, or consulting setting, including hands-on work with CMS CCLF files or comparable Medicare fee-for-service claims data.
3. Certification/Licensure: None required.
4. Training and Knowledge Required at Time of Hire: Statistical and econometric methods (regression, risk adjustment, cost-effectiveness analysis); SQL and proficiency in SAS, R, Stata, or Python, plus advanced Excel; CMS CCLF file structure (Part A, Part B, and Part D claims, beneficiary demographics, and MBI crosswalk files); episode-of-care construction and grouping methods; working knowledge of Medicare payment models and value-based arrangements (MSSP, ACO REACH, LEAD, bundled payments). Preferred: CMS ACO benchmarking, alignment, and shared savings methodology; claims data formats (837/835); CMS-HCC risk adjustment models; predictive modeling; data visualization tools (e.g., Power BI); home health, post-acute, or primary care economics
Why Work for Pathways? Pathways Health Partners is a growing company based in Leesburg, FL. We are proud of our professional yet family culture with the executive team working daily alongside our team members. We provide competitive salaries, bonuses for all team members, and a benefits package that is second to none.
- Medical Insurance for Employee and Spouse/Significant Other paid up to 100% by Pathways!
- Addition of family coverage for dependents at a fraction of the cost
- 25K life insurance for employees 100% paid by Pathways!
- Increasing Employee coverage or adding spouse/dependents at a fraction of the cost
- Vision and Dental Coverage available at a very low cost for employees, spouses, and family
- 401K retirement plan with 100% match up to 4% of annual pay
- Paid holidays
- Ample Paid Time Off (PTO) for vacation/sick/personal days
We look forward to speaking with you about this opportunity!
