Opportunity with an Anthem company that is an MA plan in CA, AZ, NV, and VA and that is participating in Medicaid space in OH, TN, and IA.
The Director of Clinical Analysis and Reporting is responsible for providing the leadership, process, and direction of clinical analytics within the Actuarial & Healthcare Economics department. The incumbent will manage a team of 10. The person will be responsible for all clinical analytics activities, including ad hoc and standard reporting (HEDIS, bed days, readmissions, etc.). Directs internal and external reporting and informatics functions for clinical data to perform substantive, comprehensive quantitative analyses to facilitate data-driven decision making and position the company competitively relative to outcomes, clinical operations and profitability.
Primary duties may include, but are not limited to: Collaborating with other WLP clinical analysis program leaders to develop and refine program evaluation metrics for clinical management programs in order to build and enhance WLPs value proposition. Lead report development and enhancement. Transform clinical analytics functionality. Provide clinical analysis and ad hoc analytical support to assist internal customers in making decisions about medical management programs.
1. Maintenance/automation of internal report sets including bed day reporting, readmission reporting, and other clinical metrics/measures. This includes internal monitoring of HEDIS and Star measures.
2. Deliver actionable analytics across the enterprise that guarantees the company meets or exceeds budgeted gross margin.
3. Provide technical and analytical support to field markets to assist in the development of sophisticated and complex analysis of utilization.
4. Lead production, analysis, and maintenance of reports used to measure and monitor utilization management, clinical outcomes, and clinical risk.
5. Perform in-depth ROI analysis on numerous clinical programs.
6. Initiate deep-dive analyses to identify root causes of performance issues on clinical Star measures, including devising custom demographic, utilization and co morbidity indices to zero in on the factors most impacting rates
7. Maintain Clinical Executive Summary for executive leadership, including regional performance metrics on innovative clinical programs, inpatient utilization, SNP compliance to CMS Model of Care requirements and YTD Star ratings on HEDIS and Part D measures.
8. Responsible for quarterly Provider Network Incentive Program calculations.
9. Provide input and analysis on effectiveness of metrics and thresholds.
10. Support Clinic Operations with EMR/EHR operational and clinical reports, including appointments/encounters, compliance with Healthy Start/Healthy Journey annual visits, and ROI of visit relative to newly-found chronic conditions with risk adjusting HCCs.
11. Provide clinical compliance reports for SRAE, HAC and SNP compliance for CMS, DMHC and DOI agencies.
12. Support the company Essentials and company Inside teams.
Requires Bachelor’s degree and 9 years of experience in financial, utilization, and quality measures of health care, managed care information development, physician profiling reporting or any combination of education and experience, which would provide an equivalent background. MBA or MPH strongly preferred. Additionally, the following competencies are key for a successful candidate:
• Clinical expertise/knowledge is required. Preferably experience with clinical quality and performance evaluation, evaluation of clinical management program effectiveness, and clinical report development/automation.
• Excellent communication skills are a must, given the degree of interaction with clinical leadership team.
• Preferably experience/background in health care field either on provider side or plan side; strong understanding of the Medicare business is a plus.
• Strong technical skills/knowledge (SQL, Visual Studio/SSRS, Excel, etc.)
• Strong financial knowledge, inclusive of P&Ls, Part C and D, Medicare Risk Adjusted Revenue, Medical Expense, Medical Loss Ratio, and SG&A. Ability to understand the drivers of profitability/loss within these discrete categories.
• Self-motivated, creative, and the ability to work effectively on cross-functional teams.
Max Populi, LLC
4628 Bayard Street, #207
Pittsburgh, PA 15213-2750
Tel: (412) 567-5279
Fax: (412) 567-5198