Description and Requirements
The Manager, Network Optimization, is the point person responsible for ensuring maximization of operational and reimbursement efficiency between Healthfirst and our network hospitals and physicians.
Responsibilities:
• Lead development of tools and processes for efficient operational and reimbursement management of hospital and physician partners.
• Evaluate Medical Trend and other standard reporting identifying Network trend drivers and operational / financial opportunities. Head actionable drill-down analyses.
• Collaborate with internal partners from DSE, Claims and Provider Operations, Contract Configuration, Product, Sales, Technology, Actuarial, Medical Management, Financial Analytics and Medical Economics teams, as well as external hospital and physician partner entities, to ensure efficient process flow and transparency around reimbursement and operational spectrum.
• Evaluate data to identify and root cause of payment integrity issues and lead cross-functional efforts to problem solve.
• Lead cross-functional initiatives to ensure enterprise-level initiatives advance Healthfirst's relationship with provider partners.
• Identify opportunities, develop and coordinate implementation of best practices for network growth and optimization.
• Optimize contractual reimbursement terms and coding across agreements, systematically identifying reimbursement outliers. Assess and standardize contractual terms and language across all provider agreements. Work across the Organization to align contractual terms and system configurations.
• Develop, own, and maintain contract renewal calendar with a timeline process for all major contract renegotiations.
• Work with Analytics and Medical Economics teams to develop actionable reporting dashboards to proactively manage Network efficiency and improve economic performance. Oversee analysis insights for DSE.
• Collaborate with Analytics, Med Econ, Actuarial, and Cost Containment areas on healthcare trend, cost and pricing related initiatives.
• Serve as an advocate for Hospital Providers within Healthfirst.
Minimum Requirements:
• A Bachelor's Degree in business, economics, healthcare administration, or a related field
• At least six (6) years of healthcare analytics experience, with at least three (3) years of experience in contract evaluation, medical cost containment, healthcare operations or reimbursement model design
• Experience with Government and proprietary payor reimbursement methodologies and unit cost management
• Strong understanding of managed care metrics (PMPM, Utilization/K and Unit Cost).
• Claims expertise including root-cause analysis, system set-up, etc
• Strong communication (both verbal and written) and organizational skills
• Ability to work collaboratively, confidently and influentially various levels of internal staff and external partners
• Demonstrated ability to focus on the most tedious of details, while also being able to solve issues that are larger and more complex
• Ability to develop relationships and partner with external and internal business stakeholders
• Proficiency with Microsoft suite (incl. MS Access) and intermediate SQL and SAS skills to access and manipulate data from a data warehouse.
• Strong data management skills with ability to manage large datasets and create standardized reports.
Preferred Qualifications:
• Masters in Business or Health Administration
Hiring Range:
• Greater New York City Area (NY, NJ, CT residents): $100,900 - $145,775
• All Other Locations (within approved locations): $86,500 - $128,690
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
Location: Michigan
Posted: Aug. 16, 2024, 4:28 a.m.
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