Medical Economics Consultant
Company: Horizon Blue Cross Blue Shield
Posted on: June 10, 2021
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
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
- 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
- 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
- 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
Requires knowledge of healthcare/managed care industry
operations and products and how they relate to key metrics within
- Requires knowledge of Horizons membership and claims databases
and the tools to effectively and efficiently navigate through such
- Requires process mapping capabilities experience in order to
develop new methodologies to achieve a desired end result.
- Requires demonstrated quantitative and financial analysis
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
- 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
- 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 &
- Requires minimum of 5 years of experience in developing complex
financial models in order to drive analyses that will support
- 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
- 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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