Director of Medical Economics (Revenue)

Position Summary: The Director of Medical Economics (Revenue) will lead the analysis and optimization of financial performance for a healthcare MSO that owns and operates a Primary Care IPA under full-risk Medicare Advantage contracts. This position will focus on revenue integrity, capitation forecasting, risk score management, and financial performance analysis. The role requires deep understanding of value-based care financial models, including Risk Adjustment Factor (RAF), capitation rates, Medical Loss Ratio (MLR), and encounter data reconciliation. The Director will provide insights that drive strategic decisions and revenue maximization opportunities for the organization and its provider network. Key Responsibilities: Revenue Forecasting & Financial Analysis • Lead forecasting and modeling of capitated revenue from payors based on risk scores, patient attribution, and contract terms. • Analyze revenue trends, RAF scores, and capitation by plan, region, and provider group. • Partner with finance and actuarial teams on budget planning and financial reporting. Risk Adjustment Oversight • Monitor HCC risk score performance and provide strategic input to improve RAF accuracy and completeness. • Analyze risk adjustment data (RAPS, EDPS, supplemental data) and collaborate with coding and clinical teams. • Work closely with the Risk Adjustment and Coding departments to evaluate impact of coding efforts on revenue. Encounter Data & Capitation Reconciliation • Ensure accuracy of encounter data submissions and completeness of risk adjustment data feeds from providers. • Reconcile capitation payments to membership files, enrollment data, and attribution models. • Identify revenue leakage and drive resolution through audits and systemic fixes. Strategic Decision Support & Reporting • Provide insights and performance reporting to executive leadership, board, and external stakeholders. • Support value-based care strategy, contract negotiations, and payor performance meetings with financial analysis. • Analyze impact of CMS model changes (e.g., HCC V28) and support transition strategies. Required Qualifications: • Bachelor’s degree in Finance, Health Economics, Actuarial Science, Public Health, or related field. Master’s or MBA preferred. • 7+ years of experience in medical economics, healthcare finance, or actuarial roles within a payor, MSO, or full-risk IPA. • Strong knowledge of Medicare Advantage capitation, HCC coding, RAF score management, and MLR. • Expertise in working with large datasets, claims, enrollment files, and encounter data. • Proficiency in SQL, Excel, Power BI/Tableau, and financial modeling tools. Preferred Experience: • Experience in delegated risk-bearing entities with full risk contracts (Medicare Advantage). • Familiarity with CMS payment methodologies, bid pricing, and trend management. • Ability to lead and influence cross-functional teams in a matrixed organization. Key Competencies: • Strategic Financial Thinking • Analytical and Quantitative Rigor • Business Acumen in Value-Based Care • Communication & Executive Reporting • Leadership & Cross-Functional Collaboration • Problem Solving and Innovation • Attention to Detail • Results-Driven Mindset AMM BENEFITS When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first: Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe. Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work. Career Development: Tuition reimbursement to support your education and growth. Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!