Managed Care Analytics Director

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Oversees analytic functions supporting Med Star Health Managed Care Operations Department which performs reimbursement and financial analyses essential to contract negotiations and system initiatives. Prepares reports in response to business needs and develops and maintains databases. Actively participates in strategic discussions re. physician hospital and diversified company rate negotiations. Evaluates and provides key input into the determination of financial strategy for payer proposals in collaboration with Managed Care leadership to ensure Managed Care goals are supported.

Develops reimbursement forecasts and monitors contract performance. Supports analytics for system-wide projects and work groups.

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standards. Complies with governmental and accreditation regulations.
• Develops reimbursement models and reports in support of managed care contracting activities by utilizing a variety of platforms and other available reporting tools to produce interactive and efficient data analytics. Frequently interfaces with external payers regarding reimbursement models and analyses in support of contract negotiations.
• Hires, trains and supervises financial analyst(s). Develops performance standards, evaluates performance and oversees personnel issues associated with staff. Ensures ongoing communication with his/her staff in accordance with Med Star values.
• Monitors payer performance and oversees profiling and reporting regarding payer utilization, profitability and financial trends including benchmarking payers against Medicare and each other.
• Oversees external market analyses. Compiles published financial and utilization information re. managed care companies. Profiles competitors or competitive clinical services. Develops a global assessment of the regional health care market to influence internal strategic decisions regarding program development and rate methodologies.
• Performs ad hoc financial reporting as needed with minimal guidance and remains current on the latest healthcare issues and reimbursement trends. Validates data extracts and analyzes any discrepancies.
• Performs other duties as assigned for both Managed Care staff and for Med Star Associates in other departments including Finance Planning and Diversified.
• Serves as a key member of interdisciplinary teams (physicians, finance and administrators) to provide operational and contract support for carve-outs including understanding the process flow and making recommendations for changes to improve efficiency and maximize reimbursement; develops and updates business rules for distribution to global billing company; conducts reporting on financial outcomes and prepares reports for regulatory agencies as needed. Acts as trouble‑shooter, interfaces with internal billing groups, providers and payers to resolve problems.
• Serves as primary contact and resource with Finance (including Patient Accounts and Patient Financial Service) regarding contract interpretation, coding requirements and other managed care reimbursement issues.
• Serves as primary contact with billing departments and/or external billing companies to secure, analyze and report physician utilization and reimbursement rates.
• Structures, coordinates, consolidates and presents financial and statistical information related to Managed Care Operations to ensure complete, accurate and timely financial reporting to management. Scope includes hospital physician, diversified business and global reporting.
• Understands functioning data requirements and revenue implications of various hospital and physician payment methodologies including Medicare IPPS, OPPS, RBRVS systems; and Medicaid fee‑for‑service and capitation arrangements.
• Works with internal clients to resolve issues, recommends process improvement regarding reimbursement issues and recommends future contract changes to enhance reimbursement and overall…