Director Medical Economics (Primarily Remote, North Carolina)

The Director of Medical Economics provides leadership and direction to the Medical Economics Team for the data analysis related to financial performance and clinical trends. This position will consider contractual required managed care efficiencies and savings targets in the drive towards data informed decisions. This position will work close with Executive Leadership to develop performance indicators with cross functional utilization. This position will direct the analytical and interpretive work to on claims expense and reimbursement data to identify areas for improvement. This position will work with operational departments to recommend cost initiatives that produce positive financial results and better member outcomes.

This position will allow the successful candidate to work a schedule that will be primarily remote and will report to Morrisville, NC as needed. There is no expectation of being in the office routinely. The successful candidates will be a resident of North Carolina or if currently residing out of state, able to relocate. 

Responsibilities & Duties

Oversee service spending and reimbursement analysis and improvements

• Oversee monitoring and analysis of service spending and reimbursement trends to identify opportunities for improving financial performance
• Work with the CFO to prepare and present regular financial reports to senior leadership, including forecasting future trend and financial performance of services
• Work with the CFO to develop yearly service budget based on operational goals and strategic plan. Incorporate collaborative work with CMO
• Direct implementation and monitoring of Medical Cost Action Plans and other Cost Initiatives
• Use actuarial data to evaluate service performance and evaluate PMPM to be used during State rate negotiations
• Monitor and forecast medical utilization patterns and flag outliers
• Lead statistical analyses to assess effectiveness of clinical programs and initiatives in collaboration with CMO or designees
• Coordinate with leadership to incorporate dashboards into business processes. Prepare reports for presentation purposes including to the Board
• Direct and implement the creation of a sophisticated analytic frameworks and functional models to forecast lines of service
• Provide leadership of interpretation of data analysis through SQL code and other similar tools such as Power BI and pivot tables

Collaborate with Departments and Stakeholders on service delivery analytics,  performance and cost

• Develop and maintain relationships with key stakeholders
• Collaborate with other departments within the organization to ensure alignment of goals and objectives.
• Work with the Clinical and Network Operations to develop and implement strategies to improve the service delivery performance
• Liaise with Clinical and Network Operations regarding financial implications of utilization and contract structures
• Liaise with IT to assist in enhancement of data warehouse BI analytics to include components that will assist in the evaluation of performance
• Work with the Business Intelligence team to design, validate and deploy health economics dashboards to support cost reduction, quality of care improvement, patient/plan member satisfaction, and program tracking
• Lead analytic efforts in assisting Provider Networks in the implementation of Value Based Payment arrangements to monitor care and member outcomes

Manage and Develop Staff

• Work with Human Resources and the EVP-CFO to attract, maintain, and retain a highly qualified and well-trained workforce
• Ensure staff are well trained in and comply with all organization and department policies, procedures, and business processes
• Organize workflows and ensure staff understand their roles and responsibilities
• Ensure the department has the needed tools and resources to achieve organizational goals and to support employees and ensure compliance with licensure, regulatory, and accreditation requirements
• Actively establish and promote a positive, diverse, and inclusive working environment that builds trust 
• Ensure all staff are treated with respect and dignity
• Ensure standards are transparent and applied consistently, impartially, and ethically over time and across all staff members
• Work to resolve conflicts and disputes, ensuring that all participants are given a voice
• Set goals for performance and deadlines in line with organization goals and vision
• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills and professional development
• Cultivate and encourage efforts to expand cross-team collaboration and partnership

Lead Performance Committee

• Oversee the Organization Performance Management Committee structure

Promote Innovation and Process Improvement

• Stay current on healthcare industry trends and regulations, and provide expert advice and recommendations to JLT and the Clinical Team
• Stay current on best practices and developments in the field of medical economics, and incorporate these into the organization's processes and systems
• Encourage a culture of continuous improvement within the medical economics team, and lead by example in promoting a culture of innovation
• Identify and execute new projects to improve Health Plan financial, quality of care, risk adjustment and clinical outcomes in collaboration with Clinical and Provider Network Operations
• Evaluate and monitor initiatives

Minimum Requirements

Education & Experience

Bachelor’s degree and seven (7) years experience in managed care performing broad range of health plan data analysis, including three (3) years managing a team. Experience must include presenting to executive leadership; analysis of medical claims, clinical assessments, and EMRs; knowledge of health plan financial and regulatory reporting standards

Knowledge, Skills, & Abilities

• Advanced knowledge of Medicaid Managed Care
• Understanding of the interface between clinical practice and outcomes research
• Advanced understanding of medical service cost forecasting
• Demonstrated leadership ability to drive results that are aligned with Alliance Mission, Vision, and Values
• Excellent research and analysis skills
• Strong Microsoft Office (Word, Excel, PowerPoint) skills
• Ability to read, develop and write SQL queries to obtain detailed data 
• History of progressive roles, knowledge of medical claims data, exposure to accounting (eg. IBNR), underwriting and claims-based, cost of care analytics 
• Team working skills, persistence, high energy, initiative, and creativity - with a proven ability to manage significant initiatives across organizations and across geographies required

Salary Range 

$98,800-$125,970/Annually 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity. 

An excellent fringe benefit package accompanies the salary, which includes:  

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility