Job Description:

SUMMARY

Under executive direction, the Associate Director Medex/DW Healthcare Economics Optum Massachusetts is responsible for all aspects of assessing, evaluating, and estimating outside medical expenses and claims data warehouse for Optum Massachusetts. Responsible for complex trend analysis and reporting to inform senior management’s decision making regarding the level of changes for financial statement reporting. Makes recommendations and provides critical professional expertise to inform senior management of amounts to record in the financial statements. Assesses and ensures the integrity, accuracy and consistency of the financial and utilization reports and databases and leads action plans for making improvements. Manages staff, consisting primarily of financial analysts. As the accountable business owner, oversees the implementation of changes to the databases, reports, and processes as dictated by changes in business needs to support the recording of outside medical expenses in the financial statements.

GENERAL DUTIES AND RESPONSIBILITIES

§ Oversees all aspects of calculation of outside claims expense and related reserves under hospital and payer risk contracts. Has overall responsibility for monthly calculation of expenses, liabilities, and accounts receivable related to payer risk contracts.

§ Manages the monthly process of outside medical expense projections, the population of reporting and analytic databases, and the required reporting and analysis of inpatient and outside utilization expenses.

§ Performs the monthly analytic review and interprets enterprise-wide, and site specific, trends and variances. Based on this analysis, makes critical recommendations to leadership on amounts to record in the monthly financial statements. Develops new financial and utilization reports and analyses as needed.

§ Responsible for supporting all amounts recorded by accounting and ensuring that proper financial controls are in place to verify amounts recorded.

§ Partners with business leaders and build strong relationships in support of financial performance; acts as a strategic thought-partner for the business.

§ Drives intersegment agreements between Optum Massachusetts and UHC entities along with understanding the financial impacts.

§ Responsible for: quarterly forecasts of all outside medical expense accounts, and related deliverables (i.e, bridges, trend reporting, supplemental schedules as applicable); Atrius forecast model for medical expense rates; creation of trends to ascertain year over year changes, experience, etc.

§ Partners across Optum Massachusetts Finance team to help lead integration activities.

§ Manages the monthly preparation of complex payer medical expense trend analyses for discussion at monthly financial statement meetings.

§ Provides recommendations on inpatient and outside utilization expense levels and directs the creation of monthly journal entry to record outside medical cost.

§ Develops and maintains on-going relationships with outside providers, payers and other external parties regarding data feeds, outside provider discounts and reinsurance issues. Directs the calculations and reconciliations of risk-sharing settlements with payers and hospitals. Has responsibility for contractually required medical claims expense and utilization reporting under risk-sharing arrangements with hospitals.

§ Works directly with the actuaries and outside auditors on evaluation of the sufficiency of recording for hospital and outside utilization expense. As the expert, provides detailed support to auditors for the purpose of their actuarial assessments. Monitors amounts recorded against claims “run-out”. Works with financial auditors to validate medical claims expense and liabilities under payer and hospital risk contract/risk-sharing arrangements.

§ In the business owner role, contacts payers to enable the data warehouse to be populated with accurate and correct data. Has responsibility for the calculation and monitoring of claims liability reserves from prior years’ risk arrangements.

§ Provides financial expertise and recommends support to clinical leadership initiatives to manage outside medical expenses by providing expertise in valuing the potential savings impact of initiatives; by communicating cost trends; and adding expertise based on claims knowledge on how performance can be tracked. Has responsibility for monthly outside medical claims utilization and expense reporting.

§ Provides leadership bridge between external and internal services of medical expertise information. Provides business rules for IT analysts to program accurate translation of monthly and annual payer data files needed to populate the enterprise data warehouse. This data warehouse is the key data repository necessary for monitoring and reporting of outside medical costs.

§ Administers all medical cost/managed care analytics related to capitated arrangements with insurances including Purchased Services and the production of all routine reports, General Ledger entries, lag grids, quarterly invoices, projections, budget and all requested ad hoc analyses. Responsible for maintenance and audit of the related claims information in the performance analytics system (DMS).

§ Works collaboratively with Contracting to provide data, analytic support, and expertise in support of payer and hospital risk management negotiations. Recommends proposals to Contracting. Supports Contracting Department discussions and evaluation of managed care contract terms; may propose changes in the contracts to the Contracting Department Leadership. Provides input and information to facilitate successful payer negotiations on expense trends and payer financial performance; works closely with the Contracting Department to estimate and manage the preparation of detail settlement documents for recovery of funds based on contractual arrangements with payers and hospital risk-sharing partners. Responsible for reconciling outside medical expenses associated with annual and interim settlements of the capitation risk contracts. Works collaboratively with the Controller to reach agreement on the final annual contract financial results.

§ In conjunction with senior management, collaborates on the annual hospital and outside utilization budgets and year-end/multi-year projections, including managing complex provider discounts and reinsurance. Directs pharmacy trend analysis related to the managed care contracts and supports understanding of these trends relative to in-house and network pharmacy expenses.

§ Manages and oversees the relationship with outside reinsurance broker and provides information according to contractual requirements. Participates in the evaluation of new reinsurance coverages and makes recommendations for program improvements.

§ Working closely with Data Analytics and Data Warehouse leadership to support data quality initiatives and direct management of transitions of payer data from new contracts or changes in contractual terms. Serves as a primary source of business expertise for Data Warehouse and Data Analytics teams.

§ Develops, on an as-needed basis, estimations of outside medical expenses for evaluation of new ventures and affiliations.

§ Performs other duties as assigned.

SUPERVISORY RESPONSIBILITIES

Manages a team of financial analyst professionals. Carries out managerial responsibilities within areas of responsibility in accordance with the organization's policies and applicable laws. Provides direction and support to staff to assure departmental effectiveness and efficiency. Responsibilities include interviewing, selecting, orienting and training employees; planning, assigning, and directing work; evaluating performance; rewarding and issuing corrective action to employees; reviewing personnel actions of staff, addressing complaints and resolving problems.

EDUCATION/LICENSES/CERTIFICATIONS

Bachelor’s degree (or equivalent experience) required, preferably in accounting, finance, mathematics or actuarial science. MBA preferred. Actuarial Certification a plus.

EXPERIENCE

Minimum of 5 years of experience in financial data analysis including experience in a managerial, supervisory or lead role required. Experience in healthcare or health insurance required. Knowledge of provider/facility contracting is a plus. Background in financial modeling and forecasting required. Prior experience in a supervisory or lead role preferred.

SKILLS

Excellent analytical and quantitative skills including statistical analyses required. Detail oriented with

strong technical writing, communication, and presentation skills. Ability to build relationships and

negotiate with external (payers and providers) and internal (finance, contracting, medical management, data warehouse) customers and develop a strong case for positive financial and other outcomes. Demonstrated project management skills and attention to detail is required. Must have strong computer skills including Microsoft Excel and SQL, and experience in computer-based modeling.

OTHER REQUIREMENTS

Able to use all electronic tools and applications relevant to the performance of the duties of the position, including but not limited to phone, keyboard, computer, and computer applications.

Performs all job functions in compliance with applicable federal, state, local and company policies and procedures.

Accesses only the minimum necessary protected health information (PHI) for the performance of job duties. Actively protects the confidentiality and privacy of all protected health information they access in all its forms (written, verbal, and electronic, etc.) taking reasonable precautions to prohibit unauthorized access. Complies with Optum Massachusetts and departmental privacy policies, procedures and protocols. Follows HIPAA privacy guidelines without deviation when handling protected health information.

WORKING CONDITIONS / PHYSICAL DEMANDS

Busy office environment with frequent deadlines and interruptions.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required of personnel so classified. The physical requirements needed to perform the duties of the position are outlined on the following page(s).

Atrius Health is committed to a policy of non-discrimination and equal employment opportunity. All patients, employees, applicants, and other constituents of Atrius Health will be treated with respect and dignity regardless of race, national origin, gender, age, religion, disability, veteran status, marital / domestic partner status, parental status, sexual orientation and gender identity and / or expression, or other dimensions of diversity.

Note: External and internal applicants, as well as position incumbents who are or become qualified disabled individuals, as defined under the Americans with Disabilities Act, must be able to perform the essential job functions either unaided or with the assistance of a reasonable accommodation to be determined by management on a case-by-case basis.

Atrius Health is an equal opportunity/affirmative action employer and does not discriminate in recruiting, hiring, training, promoting or any other employment practices on the basis of race, color, religion, sex, marital status, age, sexual orientation, gender identity, national origin, military service or application for military service, veteran or disability status.

Applicants have rights under Federal Employment Laws: Family and Medical Leave Act (FMLA);Equal Employment Opportunity (EEO); and Employee Polygraph Protection Act (EPPA).

VEVRAA Federal Contractor

Request Priority Protected Veteran & Disabled Referrals for all of our locations within the state

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