Medical Economics Analyst

Location Address:

Compensation Pay Range:

Summary:

Responsibilities:

Presbyterian is seeking a Medical Economics Analyst

This position will play a consultative role in analyzing medical data, specializing in reporting savings for payment integrity related processes, including pre-payment claim edits, pricing adjustments, and other cost-reduction initiatives. Reconciliation to vendor invoicing to ensure appropriate fee payments will also be integral to the role, along with creating and modifying SAS-based solutions for these processes.

Will be required to perform financial impact quantifications and projections that will impact budget setting. Expected to investigate, suggest, and develop different modelling avenues and varying data sets. Will own quantification process including reporting various perspectives of impact within in integrated delivery system.

Some key responsibilities include:

• Work closely with Finance, Actuarial, Underwriting, clinical operations, provider network and provider contracting teams.
• Utilize Millimans HCG Grouper model to perform drill-down analysis and research to identify the key drivers of medical and pharmacy cost trends.
• Consult with provider network/contracting, clinical operations and others on opportunities to improve utilization initiatives and mitigate trends.
• Monthly IBNR development.
• Support on Medicare Advantage D-SNP pricing and monitor D-SNP performance monthly.
• Track, document and communicate analysis and research with Med Econ teams of clients/partners.
• Provide support in development of reports as needed.

Qualifications:

• Bachelors degree in healthcare, accounting, finance or other quantitative/related fields. Masters degree is preferred.
• Four years healthcare industry experience, specifically medical economics / product performance analyzing
• Claim Procedure Coding: CPT/HCPCS, ICD DCS+PCS, DRG
• Claim Provider Coding: Bill Type, POS, Provider Types
• Benchmarking
• Risk Share Arrangements: Capitation, Shared Risk/Savings/Penalty, Quality Bonuses
• Provider/Vendor Contracting Analysis
• Claim Pricing & Provider Reimbursement
• Program/Project Pricing & Savings Valuation
• IBNR
• Forecasting/Projection/Budget
• Pricing (eg., Commercial small group/large group/individual)
• Benefit Change Determination/Pricing
• Rate Filings: Exhibits, Templates, Support
• Risk Adjustment/Risk Models (HCC, HIX, Commercial Products)
• Effective writing and oral communication skills.
• Advanced skills in MS Excel, Access, PowerPoint, Oracle SQL, and Business Objects.
• Two or more SOA exams passed is preferred.
• Tableau, SAS Enterprise Guide, and VBA programming knowledge and experience is preferred.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.