The Senior Manager, Fee Schedules, Total Cost of Care, will develop analyses and tools to help monitor financial performance and provide analytic insights into all products offered within the Healthfirst portfolio.
This key role will serve as healthcare analytics and data subject matter expert, supporting all areas of medical trend, medical cost savings, provider network informatics, and reimbursement accuracy. The ideal candidate will come from a managed care, medical economics, insurance, actuarial, or hospital background, and will be a results-oriented individual who enjoys working in a fast-paced and challenging environment.
Scope of Responsibilities:- Evaluate the financial impact of changes in CMS and NY State published fee schedules, applying financial modeling expertise and using independent judgement to determine best valuation methods.
- Understand and describe applicability of government fee schedule changes to provider reimbursement within the HF reimbursement model.
- Evaluation of reimbursement changes by provider group within the unit cost management workflows.
- Provide actionable data driven analysis to Finance, Claims, Pharmacy, Payment Integrity, Medical Management, Network, and other departments to enable critical decision making.
- Evaluate data to identify and root cause of fee schedule related payment integrity issues and lead cross-functional efforts to problem-solve.
- Develop interactive financial models to evaluate the impact of provider reimbursement changes.
- Keep abreast of New York Medicaid and Medicare reforms, reimbursement methodologies, and their impact on Healthfirst and their owner hospital performance.
- Perform ad hoc analyses.
Minimum Qualifications: - Bachelor's Degree from an accredited institution.
- At least three (3) years of healthcare analytics experience, with at least two (2) years of experience in contract evaluation, medical economics, medical cost containment, actuarial, healthcare reimbursement model design
- Extensive knowledge of managed care financial metrics (PMPM, util/k, cost/unit).
- Experience utilizing healthcare claims data to uncover valuable insights to improve financial performance.
- Expert in Government fee schedules and proprietary payor reimbursement methodologies and unit cost management.
- Experience with SAS or SQL (creates queries and manipulation of data).
- Extensive experience with Microsoft Excel (building financial models, utilizing pivot tables, vlookups, index match, and calculated fields).
- Claims experience including root-cause analysis, system set-up, etc
- Ability to work with large data sets.
- Strong written and verbal communication skills.
- Resourceful and creative in solving complex issues and working corroboratively with others on a solution.
- Ability to manage projects and project plans within stated timelines.
Preferred Qualifications: - Expertise in 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 using Tableau, Python
- Experience mentoring other team members
Hiring Range*:
- Greater New York City Area (NY, NJ, CT residents): $122,900 - $188,020
- All Other Locations (within approved locations): $105,100 - $160,480
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
