Position Summary:
The VP of Health Plan Economics will supervise, review, and manage the development and implementation of the Alignment Provider Management Report (APMR). This will include the design and development of ad hoc reports to support Provider Contracting and Network Development, analysis of product line profitability, gross margin, and expansion market analytic support.
General Duties/Responsibilities (May include but are not limited to):
- Develop and manage Alignment Provider Management Report (APMR) for current and expansion markets.
- Work with Alignment IT department to assist in the programming and mapping of various financial and key performance indicators within APMR
- Work with Alignment Accounting staff to reconcile and verify the integrity of APMR yearly and monthly financial data to the General Ledger
- Work with Alignment FP&A team to incorporate budget data and assumptions into APMR.
- Work with Alignment Claims department to validate the integrity of claim payment within APMR
- Work with Alignment Provider Contracting and Network Development staff to analyze contract rate trending impact and anomalies (hospital modeling, SNF/home health modeling, others).
- Work with Alignment UM and Clinical operations department to validate and reconcile key authorization admit and bed day metrics to actual paid claim data.
- Support Regional VP’s in providing analysis of monthly APMR data and ad hoc reporting of key performance indicators.
- Support finance and operations in developing predictive KPI’s to better forecast and manage the business of Alignment.
- Maintain and enhance finance business intelligence tools such as Qlik Sense and Power BI
- Support claims trend assumptions for budgets and bids, validation of MLR on bids compared to historical trends, unit cost trends for inpatient/outpatient costs
- Oversee risk pools/gain shares/provider incentives and manage quarterly or annual payments
- Oversee Monthly Operating Reports (MOR) for clinical and network teams, highlighting MLR trends, utilization and unit cost trends, out of area claims, areas of opportunities and risks
- Oversee configuration and administration of monthly capitation payments to providers
- Plan, prioritize, assign, supervise and review the work of staff responsible for providing APMR services.
- Provide or coordinate staff training as necessary; work with employees to correct deficiencies; implement discipline procedures.
- Work with all levels of staff to direct, assist, and explain the APMR process as needed.
- Demonstrate commitment and attendance sufficient to complete the duties of the position as required.
- Perform related duties similar to the above in scope and function as required.
Supervisory Responsibilities:
Oversees assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees.
Minimum Requirements:
1. Minimum Experience:
- At least 10 years of experience in financial/data analysis.
- At least 10 years of managerial experience
2. Education/Licensure:
- Bachelor of Science in Business preferred
3. Other:
- Knowledge of principles and practices of finance administration in accounting, budgeting, and auditing.
- Understanding of CMS Premium payment methodologies to MA Health Plans. Understanding MMR documentation, premium payment calculations, Risk adjustment Factors (RAF), other premium adjustments, and file layout.
- Understanding of CMS provider payment methodologies (DRG, RBRVS, etc.)
- Understanding of operations, services and activities within a Data Warehouse environment (Claim Data, Membership, Eligibility, and Revenue Data, etc.)
- Understanding provider capitation contracts, development of capitation rates, contract carve outs, performed comparative analysis to Fee For Service.
- Exposure and ability to use Actuarial studies related to IBNR and LDS
- Understanding of provider contracts for medical groups, independent physicians, and hospitals.
- Understanding of payment methodologies for Hospitals (DRG, Per Diem, % of Billed, etc.) and Physicians (RBRVS, FFS, Capitation, etc.) and other ancillary providers.
- Develop new analysis and approaches to the use of data that allow fresh insights into the business of the company
- Be able to work to goals with low level of supervision
- Communicate clearly and concisely, both orally and in writing.
- Establish and maintain effective working relationships with those contacted in the course of work.
- Maintain effective audio-visual discrimination and perception needed for making observations; communicating with others; reading and writing; and operating assigned equipment.Maintain mental capacity which allows the capability of making sound decisions and demonstrating intellectual capabilities.
Work Environment:
- The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
United States
