+--------------------------------------------------------------------------+ | | | | | JOB SUMMARY: | | | | The Director of Clinical & Payment Analytics will play an important role | | in the transformation of the BMC System and its financial stability. The | | Director will promote the use of data and proprietary | | algorithms/analytics as a source of intrinsic competitive advantage to | | directly impact medical management and spend through the application of | | analytics. The candidate will report directly to the Vice President of | | Provider & Clinical Analytics and lead the analytic and reporting | | functions as they pertain to the support of medical management | | functions. The candidate will also lead the development of a targeted | | claims audit pipeline to move portions of the Plan’s claims audit | | function upstream in the claims payment cycle. The Director will have a | | strong focus on driving financial performance through rigorous | | performance measurement, effective communication, and data integrity. | | This is a high exposure position, both internally and externally and | | will work closely with senior leadership throughout the Plan and the | | System. | +--------------------------------------------------------------------------+ | | | | | KEY FUNCTIONS/RESPONSIBILITIES: | | | | | | | | CLINICAL ANALYTICS | | | | - Develop, maintain, and leverage a best in class analytics | | infrastructure to support BMCHP’s Office of Clinical Affairs and its | | medical management strategy. | | - Lead the development of critical analytic processes comparing the | | Plans performance against benchmarks to determine areas of focus and | | opportunity and help maintain industry competitiveness | | and intelligence. Present data and findings with insights to the | | clinical leadership teams to help launch performance | | improvement initiatives. | | - Partner with Clinical team leadership to develop program performance | | metrics and KPI’s to measure the new performance improvement | | initiatives launched. Build and maintain dashboards that are | | critical to fine tuning operations, evaluating performance of | | medical management initiatives as well as serve as a leading | | indicator of medical spend. | | - Develop relationship with analytic counterparts at UM vendors and | | build robust processes to measure ROI on vended programs, jointly | | present at JOC and build overall monitoring capability to identify | | new and missed opportunities based on utilization and cost trends. | | - Lead the development of analytical processes to measure ROI on | | internally managed UM initiatives and provide insights to leadership | | on medical management strategy. | | - Provide thought leadership and subject matter expertise on | | clinical analytics. | | | | | | | | PAYMENT ANALYTICS | | | | - Sets strategic analytics direction to identify claims that may have | | resulted in overpayments and works cross functionally with provider | | audit team to validate findings. | | - Develop a robust analytics process to analyze claims by place of | | service, type of claim, type of service, provider entity etc. to | | identify variation and discrepancies in billing practices | | - Work with the provider audit team to develop a prioritization | | sequence for audit of outlier claims | | - Develop a process improvement cycle incorporating feedback from | | audit teams to continuously monitor and optimize the identification | | of audit worthy claims while striking the right balance between | | resources and recovery. | | - Develop processes and standards to measure the claims analytics | | activity as it relates to overpayments, audits and recoveries. | | Develop KPI’s to inform leadership of the financial value generated | | by the payment analytics activity for the organization. | | | | | | | | GENERAL | | | | - Develop processes and standards to ensure data and reporting | | integrity at all times and even in times of significant change. | | - Attract, retain, and develop talent that upholds BMC’s culture and | | analytic capabilities | | - Directs analysts through coaching, work allocation, problem | | resolution, performance evaluation, and related | | supervisory activities. | | - Provide leadership, direction and development to staff to promote | | professional growth and to upgrade departmental talent | | | | | | | | | +--------------------------------------------------------------------------+ | SUPERVISION EXERCISED: | | | | - Directs 3-5 staff | | | | | +--------------------------------------------------------------------------+ | SUPERVISION RECEIVED: | | | | - General supervision is received weekly. | | | | | +--------------------------------------------------------------------------+ | QUALIFICATIONS: | | | | | | | | EDUCATION: | | | | - Bachelor’s Degree in Finance, Health Care Administration, Business | | Analytics or related field required. | | | | | | | | PREFERRED/DESIRABLE: | | | | - Master’s Degree preferred | | | | | +--------------------------------------------------------------------------+ | EXPERIENCE: | | | | - 10+ year’s progressively responsible experience in healthcare | | setting, preferably in the payer side leading Clinical Analytics. | | - Possess hands-on knowledge of health care systems including claims | | and authorizations. | | - Advanced SAS and/or SQL programming | | skills. Proficient in Microsoft Excel. | | | | | | | | PREFERRED/DESIRABLE: | | | | | +--------------------------------------------------------------------------+ | CERTIFICATION OR CONDITIONS OF EMPLOYMENT: | | | | - Pre-employment background check | | | | | +--------------------------------------------------------------------------+ | COMPETENCIES, SKILLS, AND ATTRIBUTES_:_ | | | | | | | | - Strong leader of analysts with an ability to translate findings into | | insights | | - Ability to use well developed interpersonal skills to direct and | | influence the efforts of others, both internally and externally. | | - Must be able to conceptualize and envision the impact of change, and | | propose new ways to do business. | | - Ability to meet deadlines, multi-task, problem solve and use | | appropriate technology to analyze business problems. Project | | management skills a plus. | | - Strong communications skills, both verbal and written, are required. | | - Strong understanding of health care data and | | analytical methodologies. | | - Strong team player. | | - Effective collaborative and proven process improvement skills | | | | | +--------------------------------------------------------------------------+ | WORKING CONDITIONS AND PHYSICAL EFFORT: | | | | | | | | - Work is normally performed in a typical interior/office | | work environment. | | - No or very limited physical effort required. | | - No or very limited exposure to physical risk | | | | | +--------------------------------------------------------------------------+
Required Skills Required Experience
Physical requirements include: standing, sitting, walking, using hands and fingers, reaching including reaching above the shoulder, talking and hearing: visual acuity; occasional stooping or crouching and occasional lifting a maximum of 50 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job.