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Medical Economics Consultant

Company: Horizon Blue Cross Blue Shield
Location: Hopewell
Posted on: June 10, 2021

Job Description:

Job Summary:

This position is responsible for Value Based Program analytics, future program evolution and development. Responsibilities include the build and on-going reporting of analytics data to develop value-based programs, targets, and payments for OMNIA and other partners and the on-going management & assessment of these programs; Alliance/Value Based Program Partner program presentation development; and the management of key HCM operational reviews, including the Monthly Operating Review (MOR) and METEOR 2.0 which is presented to HCM senior leaders and related division senior leadership.

Coordinate and produce financial reporting and lead analytical activities that support P&L evaluation consistent with the business management process. Drive the effective development and tracking of key division medical cost savings action plans and strategic investments. Present these action plans and strategic investments to HCM senior leaders.

A key responsibility will be to interface and manage cross-functional initiatives as well as present to external parties such as but not limited to Alliance Partners. Key areas of focus will include: developing a comprehensive understanding of the composition of monthly and year-to-date revenue and medical costs, including the identification of key variance factors between actual results and divisional and related enterprise-wide budget. This understanding will lead to this position interfacing and collaborating across the enterprise to lead, analyze and evaluate key initiatives that will drive profitable segment performance. As such, present and review for assessment by actuarial and underwriting in determination of future program costing. This position will also establish and manage the comprehensive behavioral health reporting and analytics management process which will support the Value Based Program transformation and the Organized Systems of Care initiatives.


  • Leads the Healthcare Management Reporting process (partnering with analytics and actuarial) aimed at the presenting and understanding of specific HCM P&L performance including, but not limited to (i) Variance Analysis/Commentary - Actual vs Budget/Plan and Prior Year (ii) Revenue detail and components (iii) Medical Cost detail and trend drivers (iv) Performance of Medical Cost Action Plans (v) Product Mix and (vi) Market Segment financial results. Includes accountability for leading projects and initiatives to drive performance and enterprise-wide interfacing with business leaders and subject matter experts.
  • Establishes a management process with the specific purpose of identifying and challenging medical cost performance through the evaluation of business metrics including utilization and unit cost trends. Collaborates with enterprise leadership teams representing medical, clinical, pharmacy, and network to identify areas for performance improvement and to continuously develop appropriate medical cost action plans. Partners with the Actuarial and Medical Cost Strategy teams to validate medical cost action plans, track performance and ultimately report results to senior management.
  • Identifies and informs Underwriting (VP, Chief Underwriter) and Segment Leadership of medical and pharmacy cost trends (including Medicaid) which require future funding through premium and rate setting and develops analytics that support such pricing strategies.
  • Manages key HCM business reporting and analytics deliverables, including the METEOR 2.0 and HCM Monthly Operating Review (MOR), which are aimed at informing senior leadership of key performance metrics and trends leading to key business decisions.
  • Oversees the Value Based Program TME Dashboard reporting including executive summary presentations and detailed medical cost trend performance. Leads the presentation to Value Based Program TME partners with specific focus on key observations and recommendations aimed at reducing medical cost trend while maintaining quality levels.
  • Evaluates the feasibility of strategic initiatives and new business opportunities and advised senior management of recommendations. This includes providing support in developing financial program scenarios for current and potential Value Based Program partners related to program evolution or customization. Actively participates within the development of the future state of Value Based Programs as well as other creative partnership strategies such as joint ventures.
  • Leads analytics initiatives to support and grow our Value Based Program portfolio through the financial modeling of various program conceptual designs and evolutions. Supports senior leader decision-making through scenario analysis and presentations.
  • Develops external Value Based Program financial presentations in order to display program benefits for Partners with the ultimate aim to transition to full risk arrangements.
  • Works closely with the Value Based Program team to understand the operations of the program including attributed membership and shared savings calculations and supports the integrity of the Program through objective review and validation. Identifies data requirements for internal and external reporting purposes and collaborates with Medical Economic and Analytics team members to develop efficient and effective data sources to run various levels of analytics.
  • Collaborates with the Network team to develop a comprehensive Network unit cost model, including both hospital and professional providers, in order to evaluate year-to-date actual unit cost against target expectations.


  • Requires general knowledge of the components underneath medical cost and utilization trends, as well as how to appropriately present year-over-year comparisons to specifically identify variances/changes to budget and prior year.
  • Requires knowledge of Commercial and Medicare market sectors and products.

Requires knowledge of healthcare/managed care industry operations and products and how they relate to key metrics within financial statements.

  • Requires knowledge of Horizons membership and claims databases and the tools to effectively and efficiently navigate through such databases.
  • Requires process mapping capabilities experience in order to develop new methodologies to achieve a desired end result.
  • Requires demonstrated quantitative and financial analysis skills.

Skills and Abilities:

  • Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Outlook. Should be knowledgeable in the use of intranet and internet applications.
  • Requires the ability to express thoughts clearly and concisely, both verbally and in writing.

Requires a demonstrated aptitude for analytical thinking and the ability to report findings in an accurate manner.

  • Requires the ability to research and resolve problems through interaction with company-wide personnel.
  • Requires the ability to work independently with minimal direct supervision and exercise sound business judgment.
  • Requires advance knowledge of Excel.
  • Requires experience with Word and PowerPoint.


  • Requires Bachelors degree from an accredited college or university, preferably in accounting, actuarial, finance or a related field.


  • Requires a minimum of 8 years of experience in health care/managed care with direct responsibility within a Financial Planning & Analysis (FP&A) and/or Medical Cost Management & Analysis discipline.
  • Requires minimum of 5 years of experience in developing complex financial models in order to drive analyses that will support business decisions.
  • Requires a demonstrated progressive understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, product pricing, network and provider contracting, and utilization management.
  • Requires a minimum of 5 years of demonstrated experience collaborating effectively with business partners such as Analytics, Actuaries, FP&A, and/or Medical/Rx/Clinical Operations in order to develop solid skillsets with the following disciplines: medical cost analysis, development/validation/tracking of medical cost action plans, return-on-investment scenarios, market segment premium development, monthly financial reporting and variance analysis, annual business plan/budget development and presentations to management.
  • Requires demonstrated technical skills with database concepts, data analysis development, data warehousing, and data extraction tools (ex. SAS, SQL).
  • Requires demonstrated understanding of P&L management principals, actual versus budget variance analysis, and general knowledge of budgeting and planning principals.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Keywords: Horizon Blue Cross Blue Shield, Trenton , Medical Economics Consultant, Other , Hopewell, New Jersey

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