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|Executive Director, Medical Economics|
Company: University of Miami
Location: Coral Gables, FL
Employment Type: Full Time
Date Posted: 08/13/2022
Expire Date: 10/13/2022
Job Categories: Healthcare, Other
Executive Director, Medical Economics|
The Department of Business Development and Managed Care is currently seeking an Executive Director of Medical Economics. The Executive Director of Medical Economics (ME) reports directly to the Associate Vice President of Managed Care and is responsible for the keen senior direction of all staff, systems, processes, procedural methods, and policies utilized by the Medical Economics business unit to support the sustainable maximization of UHealth net revenue yielded by its Managed Care and ďvalue-basedĒ contracts. Medical Economics, a business unit within the UHealth Managed Care Department, provides the quantitative support required to manage an enterprise portfolio of over 70 contracted payors with a combined annual net revenue of over $1.8 billion, nearly 85% of the health systemís income. The Executive Director provides oversight and leadership for the business unitís following enterprise spanning core functions:
Contract Modeling and Negotiations. Most of UHealthís major payor contracts are on a 3-year renewal cycle, and in a typical year the department can negotiate $350-$500 million worth of business. The Medical Economics unit establishes the negotiated structure for all hospital, professional, and ambulatory surgery center rate proposals; and conducts modeling exercises with historic populations to assess the potential financial impact on net revenue during each negotiation cycle.
Managed Care Strategic Analysis and Reporting. Contracted Commercial and ACA Health Insurance, Medicare Managed Care, and Medicaid Managed Care comprise approximately 85% of the health systemís annual net revenues. The exceptionally volatile South Florida health insurance market and UHealthís contract portfolioís response to it requires ongoing monitoring and assessment of internal and external data to inform the contracting economics and tactical direction of Uhealthís relationships with local and national payors. Medical Economics provides this strategic business intelligence.
Value Based Agreement Information Infrastructure. Managed Service Organization (MSO) style risk sharing arrangements are quickly becoming the mode of contracting for Medicare Advantage plans, Uhealthís second largest class of payor agreements. Medical Economics develops and maintains an analytic and operational information infrastructure for the MSO pilot Population Health program operated in the Department of Managed Care.
Business Oversight of Payor Plan Schema and Enterprise Business Reporting Categories. The Executive Director of Medical Economics facilitates the coordination of Uhealthís multidepartment financial business units to maintain and curate the organizationís enterprise schema of payors and benefit plan codes. This responsibility also includes the architecting of the organizationís Enterprise Reporting Categories used to accurately group insurance payor and insurance plan financial activity within lines of business. The Executive Director of Medical Economics conducts a monthly interdepartmental forum and organizes ad hoc projects to maintain the integrity of plan schema.
This position oversees the quantitative component of all managed care negotiations and relationships from initial assessment of a payors relative performance and positioning in the market and UHealthís payor mix; through multiple iterations of rate proposals and counterproposals; to auditing of payor system configurations shortly after the execution of an agreement.
CORE JOB FUNCTIONS
The Executive Director of Medical Economics reports directly to the UHealth Associate Vice President of Managed Care and is accountable for all activities of the Medical Economics unit. The Executive Director directly supervises the Medical Economics teamís Director of Contract Modeling and Negotiations; and the Director of Managed Care Strategic Analysis and Reporting; and overall leadership to the teamís Managers and Analysts. The Executive Director establishes standards for the design and implementation of processes and systems for the evaluation and analysis of market conditions and the crafting of UHealthís contracting strategy as a response. Supervises the creation of models and methods for quantifying historic payer performance and projecting revenues associated with negotiated proposals all using sound mathematical and statistical methods. Develops techniques that measure contractual reimbursement rates and methodologies to enhance net revenue or increase administrative efficiency. Directs the production of quarterly and ad-hoc payer performance report summaries; and prepares and presents financial impact forecasts and comparisons for all major payers and the overall managed care portfolio. Oversees the management and monitoring of UHealth managed care agreements, including financial analysis, utilization analysis, and expense tracking and trending for both managed care contracts and value-based agreements. Establishes and continuously assesses the effectiveness of internal processes w ithin the unit and compliance with University policies and procedures. Ensures employees are trained on all internal processes and on University policy and procedures.
Department Specific Functions
Responsible for budgeting, procurement, and direction of the Medical Economics teamís resources. The Executive Director meets regularly with team members to assign and monitor progress on team projects and offer assistance or guidance when necessary. Oversees the crafting of modeled optimized rate proposals for Hospital, Professional, and Ambulatory Surgery Center contracting. The Executive Director uses a comprehensive understanding of the payment methodologies used by payors for each type of provider to assess modeled projections. Serves as a subject matter expert for analytic techniques and modeling methodologies. Provides consultative input and direction for enterprise regulatory reporting involving price transparency, or the publishin g of UHealth contracted reimbursement rates. Oversees and curates the standardized enterprise structure of UHealth benefit plan codes and business reporting categories. The Executive Director facilitates a monthly interdepartmental forum to address changes or redesign needs related to the enterprise payor/plan schema. Develops the methods and measures used for managing financial information pertaining to UHealthís Population Health program within the Managed Care Department. This includes systems and processes used to provide clinical feedback for closing care gaps; for simulating a risk agreement tied to a medical loss ratio; and for calculating a monthly payment process for participating MSO providers.
This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.
Masterís degree in relevant field; or Bachelorís degree in relevant field plus 10 years of direct demonstrable experience.
Minimum 5 years of relevant experience with evidence of progressive leadership responsibilities directing a healthcare analytic unit; minimum 10 years relevant progressive experience with progressive leadership if used in lieu of a Masterís degree.