Position is responsible for the identification and management of vendor contracts and contracting opportunities, global risk arrangements, the development of ACO MSO capabilities, the analysis and modeling of unit cost and medical expense trend arising from provider contracts, payment policies, medical service categories, payment integrity, processing rules, vendor relationships and internal programs
• Manage and evaluate third party leased network (TPN) arrangements ensuring optimal market results, administration and work collaboratively with impacted parties to implement
• Oversee management and renewal (as applicable) of global risk arrangements
• Develop, implement and manage Accountable Care infrastructure. Identify entities eligible for ACO relationship, engage, contract and implement
• Oversee performance management of capitated specialty vendor arrangements, including UM only and full risk arrangements.
• Develop, direct and implement methodologies for evaluation and comparison of medical cost for contract performance and modeling purposes
• Provide support in areas of medical cost management and variance analysis. Drive the performance of ongoing analysis and evaluation of benefit design impact and contract terms for existing and new plans
• Recommend actionable steps to positively impact identified unit cost budget variances, work collaboratively to implement, and measure impact of changes
• Subject Matter Expert in coding and reimbursement
• Regular attendance is an essential function of the job. Performs other duties as assigned or required.
• Identification and implementation of unit cost management opportunities
• Implementation of market changing ACO model succeeding in provider plan aligned incentives and improved patient care outcomes
• Optimization of TPN arrangements
• Effective reimbursement analytic support and self service tool development
• BA required
• MPH, MBA preferred
• Minimum 10 – 12 years relevant business experience
• 5 -8 years management experience
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...