Medical Economics Analyst - Remote

Presbyterian is seeking a Medical Economics Analyst

This position will play a consultative role in analyzing medical data, specializing in reporting savings for payment integrity related processes, including pre-payment claim edits, pricing adjustments, and other cost-reduction initiatives. Reconciliation to vendor invoicing to ensure appropriate fee payments will also be integral to the role, along with creating and modifying SAS-based solutions for these processes.

Will be required to perform financial impact quantifications and projections that will impact budget setting. Expected to investigate, suggest, and develop different modelling avenues and varying data sets. Will own quantification process including reporting various perspectives of impact within in integrated delivery system.

Fundamental Components:

Use SAS to generate claim lines either denied or price adjusted in a consolidated dataset
• Work closely with Payment Integrity team in validating savings and diagnosing potential discrepancies with vendor invoices
• Recommend, implement, and oversee maintenance of processes used in reporting and reconciliation
• Provide support in development of reports as needed.
• Claim Pricing & Provider Reimbursement: fee schedules and Pricing Systems

• This is a Full Time position - Exempt: Yes
• Remote: Open to remote applicants in the United States, except for the following states: California, Illinois, North Dakota, New York, Ohio, Washington and Wyoming
• Work hours: Days

Ideal Candidate:

• Masters degree.
• Four years healthcare industry experience, specifically medical economics

• Bachelors degree in healthcare, accounting, finance or other quantitative/related fields. Masters degree is preferred.
• Four years healthcare industry experience, specifically medical economics / product performance analyzing
• Claim Procedure Coding: CPT/HCPCS, ICD DCS+PCS, DRG
• Claim Provider Coding: Bill Type, POS, Provider Types
• Benchmarking
• Risk Share Arrangements: Capitation, Shared Risk/Savings/Penalty, Quality Bonuses
• Provider/Vendor Contracting Analysis
• Claim Pricing & Provider Reimbursement
• Program/Project Pricing & Savings Valuation
• IBNR
• Forecasting/Projection/Budget
• Pricing (eg., Commercial small group/large group/individual)
• Benefit Change Determination/Pricing
• Rate Filings: Exhibits, Templates, Support
• Risk Adjustment/Risk Models (HCC, HIX, Commercial Products)
• Effective writing and oral communication skills.
• Advanced skills in MS Excel, Access, PowerPoint, Oracle SQL, and Business Objects.
• Two or more SOA exams passed is preferred.
• Tableau, SAS Enterprise Guide, and VBA programming knowledge and experience is preferred.

• Work closely with Finance, Actuarial, Underwriting, clinical operations, provider network and provider contracting teams.
• Utilize Millimans HCG Grouper model to perform drill-down analysis and research to identify the key drivers of medical and pharmacy cost trends.
• Consult with provider network/contracting, clinical operations and others on opportunities to improve utilization initiatives and mitigate trends.
• Monthly IBNR development.
• Support on Medicare Advantage D-SNP pricing and monitor D-SNP performance monthly.
• Track, document and communicate analysis and research with Med Econ teams of clients/partners.
• Provide support in development of reports as needed.

About Presbyterian Healthcare Services
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.

The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges, webinars, and screenings - with opportunities to earn gift to earn gift cards and other incentives.

As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships. Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.