As a Senior Manager of the Medical Economics Medical Expense Review Team, you will define, develop and provide analytical support and executive level presentations to drive the decision making process for internal leadership across assigned Medicaid Plans. The primary goal of this team is to provide accurate, actionable data and analysis tailored towards utilization and unit cost management to support each Plan in meeting their annual targets.
- Align with senior Local Plan and Medical Economics leaders to ensure analytics are supporting Plan strategy and financial targets.
- Present recommendations to management based on analysis.
- Manages team of analysts and provides guidance, organization, priority setting, and analytical support to drive data sharing used to formulate effective network contracting, medical policy, and utilization management strategies.
- Work with Operations to ensure payment accuracy based on specific finding and analysis.
- Ensures medical cost opportunities are being identified and shared on a consistent basis for the assigned Plans.
Additional detail on this position's primary duties:
Lead and drive complex analytical projects to research and explain utilization and unit cost medical cost drivers across the entire Enterprise. Medical cost analytics includes: review of utilization and unit cost trends for Medicaid line of business, determining outliers by researching claims data (both medical and pharmacy), reviewing provider contractual rates and agreements, researching claims payment policies, identification of outliers via benchmarking evaluations. Develops standards and best practices for MER team.
Develops/mentors team members. As a mentor, help answer questions for team members who need guidance with analysis and research. This includes, but not limited to: understanding provider reimbursement methodologies, mathematical techniques for sizing contract changes, claims payment policies, and navigating the cross-matrixed organization. Schedule weekly 1:1s with team members, organize and facilitate routine training sessions to ensure ongoing skill development of each team member.
Works cross-functionally throughout the enterprise to assist our customers in achieving unit cost goals and pharmacy cost reduction initiatives. The goal of the collaboration is to inform and engage enterprise leaders on estimated unit cost changes and pharmacy initiatives to help ensure they achieve their applicable targets. Develop best practices and presentations to facilitate/lead these discussions.
The typical pay range for this role is:
Please keep in mind that this range represents the pay range for all positions in the job grade within which this position falls. The actual salary offer will take into account a wide range of factors, including location.
• 8 or more years of experience in the managed care industry and/or analytics of finance.
COVID-19 Vaccination Requirement
CVS Health requires certain colleagues to be fully vaccinated against COVID-19 (including any booster shots if required), where allowable under the law, unless they are approved for a reasonable accommodation based on disability, medical condition, religious belief, or other legally recognized reasons that prevents them from being vaccinated.
You are required to have received at least one COVID-19 shot prior to your first day of employment and to provide proof of your vaccination status or apply for a reasonable accommodation within the first 10 days of your employment. Please note that in some states and roles, you may be required to provide proof of full vaccination or an approved reasonable accommodation before you can begin to actively work.
- In depth knowledge of healthcare claims data
- Strong analytical ability and familiarity with advanced financial and healthcare modeling concepts within excel
Contract payment terms and relationship to claims payment
- Advanced college degree at the Masters level
- Ability to develop analytical tools and models
- Advanced analytical tools – SAS, SAS Enterprise Guide, SQL experience
Demonstrated ability to:
Lead team members in proactive analysis/research around utilization and unit cost medical costs drivers for the assigned Medicaid Plans.
Lead and manage a team of colleagues with diverse skills to work collaboratively across departments in a highly matrixed organization to communicate potential opportunities to mitigate trend divers
Ideate and utilize analytical models to determine the savings opportunities to mitigate medical cost drivers. Working across Plan leaders to understand their savings initiatives to determine if initiatives can be shared across other Plans
Lead discussions and presentations with the Plan leadership and National leadership about medical cost drivers and mitigating cost opportunities. Facilitate/host discussions to discuss the medical cost drivers with Plan leadership to act on the drivers: Plan CEO, Plan CFO, Market Clinical Leads, Actuarial, Chief Network Officer, Operations
Work in a matrixed cross-functional organization to help achieve operational targets
Perform complex functions in Excel, MS-Access, and Web-based query tools (MCM, data warehouse).
Demonstrate innovation and leadership in achieving results
Demonstrates critical thinking and expresses ideas clearly, concisely and logically from a cross functional perspective.
Manage conflicting priorities and multiple projects concurrently.
Develop standards and best practices for MER team.
Bachelor’s Degree or equivalent work experience required.
Bring your heart to CVS Health
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CVS Health is an affirmative action employer, and is an equal opportunity employer, as are the physician-owned businesses for which CVS Health provides management services. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex/gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.