Job Description

Must Haves:

• Bachelor's degree (preferred fields: Finance, Health Services Administration, Informatics, Data Analytics)
• 4+ years in Managed Care, with strong exposure to:
• Commercial Insurance payors (Blue Cross Blue Shield, UnitedHealthcare, Cigna, Aetna)
• Managing payor contracts and provider analytics
• Forecasting and trend analytics - financial modeling & risk forecasting
• Supporting the hospital side (not payor side)
• Excel Expertise:
• Advanced formulas (IF statements, VLOOKUPs), macros, and data modeling.
• Ability to take Excel analysis to a higher level (moderate to advanced proficiency).
• Proactive and solution-oriented - does not wait for answers.

Plusses :

• Experience with multi-state contracts.
• Experience with hospital financial modeling
• Familiarity with EPIC (reporting experience preferred)
• EPIC HB (hospital billing certification)

Role overview:

This role is focused on managed care within the payor space, commonly referred to as medical economics. They collaborate with negotiators who engage with BUCA payors to establish new reimbursement rates and build rate structures for future periods. This role is responsible for analyzing and evaluating financial and economic data related to healthcare costs, managed care payer rates, and reimbursement. It focuses on identifying financial trends, applying reimbursement methodologies, leveraging data tools, and developing financial models to manage revenue effectively. The position involves conducting complex analyses of managed care contracts and proposals, reviewing fee schedules for compliance, and transforming raw data into actionable insights to support executive decision-making. Additionally, the role ensures collaboration with managed care teams across multi-state divisions and represents the organization in discussions with payers across various markets.

Key Responsibilities

• Rate Structure Development: Build and analyze reimbursement rate structures for upcoming years.
• Data Analysis & Modeling: Pull 1–2 years of historical data and use Excel to model trends and methodologies, including stop-loss and per diem models.
• Forecasting: Project future reimbursement rates and financial impacts based on historical data, market trends, and modeling assumptions.
• Financial Analysis: Evaluate monetary impacts and account-level details to support decision-making.
• Contract Review: Interpret payor contract language and translate reimbursement terms into formulas for financial modeling.
• Market Insight: Stay informed on active contracts and payor trends to guide negotiations and rate-setting strategies.

Job Description:

• Researches and analyzes managed care data from various financial systems and interface tools.
• Performs complex and varied healthcare data analysis, including financial modeling and risk forecasting.
• Identifies and implements improvements in quality control and timeliness of reporting.
• Extracts, collects, analyzes, and interprets health utilization and financial data.
• Interprets and analyzes data from various sources using knowledge of healthcare managed care contracts and administrative claims data.

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