Job description
Overview:
The Director delivers insights and creates analytical capabilities that will enable the organization to manage an efficient network. Evaluates methodologies applied in Commercial, Medicare, and Medicaid products to support best practice application in HNE agreements. Develops recommendations for optimum rate structure and terms to achieve HNE’s goals in negotiations. Uses data to provide recommendations on reimbursement as well as design of value based terms. Manages multiple, complex projects using all available resources, while exercising good independent judgment toward meeting HNE goals and objectives. Collaborate with HNE IT and Finance teams to determine appropriate data sources and data needed to support contracting analytics.
Responsibilities:
- Leads the design and development of strategic and accurate data analytics for provider contract negotiations
- Use publically available price transparency data sources to understand competitor and health plan information and identify opportunities for HNE to optimize its contracting opportunities
- Provide subject matter expertise on design and development of innovative value-based and shared savings contracts. Engages in analysis of various options and makes recommendations to leadership
- Delivers insights into the performance of value-based contracts, drivers of that performance, and identifies actionable opportunities for improvement to leadership, clinical operations and managed care contracting
- Develops integrated analysis, projections, standardized reports, and presentations to reflect impact and actual performance trends
- Provides consultative support for negotiation strategy and joins provider negotiations as appropriate
- Performs ongoing market analysis using benchmarking across HNE network providers using a standard CMS approach with various types of reimbursement methodologies (DRG, RVUs, ASC, OPPS, AWP, ASP)
- Provides analytical support and consultation for all contracting and network expansion efforts, including bundled payment contracting, pay-for-performance contracting, etc.
- Implements needed changes using contracting analytical tool sets and database
- In support of pricing and forecasting, works collaboratively with Finance and Actuarial staff by identifying, analyzing and presenting drivers of unit cost and utilization changes by product (Commercial, Medicare Advantage and Medicaid)
- Monitors contract financial performance against projections to identify anomalies
- Performs sensitivity analysis to identify risk/exposure associated with payment changes
- Prepares and effectively presents results to senior leadership, and other key stakeholders, for review and decision making activities
- Assists in development of contractual language
- Advances best practices in documentation, data quality assurance and data management
- Provides guidance, mentoring, and training to team members and HNE stakeholders
A Bachelor’s degrees (MBA preferred) in Finance, Actuarial, Data Science or related field. Experience working in the Healthcare industry in Managed Care, Provider Group, or Hospital analytics. Minimum of 7-10 years’ progressive experience.
- Minimum of 7-10 years progressive responsibility leading and managing analytical teams, providing decision support to senior and executive leadership.
- Advanced SQL or SAS experience including writing new queries on an ad-hoc basis
- Advanced level analytics, statistics
- Extensive background in modeling provider contracts for negotiation purposes
- Extensive experience in both fee for service and value-based contracting
- Advanced detailed experience with APR-DRG, MS-DRG, OPPS, ASC Grouper, RBRVS and pharmacy reimbursement methodologies
- Experience developing data specifications and quality assurance protocols for analytic workflows
- Detailed knowledge of hospital, ancillary and professional billing including CPT, HCPCS, DRG, ambulatory surgery coding
- Trusted professional with a strong customer service orientation as well as the ability to work effectively with people at all levels is essential
- Familiarity with managed care health insurance products including Commercial, Medicare Advantage and Medicaid lines of business
- Detail-oriented and deadline-driven with the ability to manage multiple projects simultaneously
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