Senior Healthcare Analyst

Primary Responsibilities

• Participates in the development and ongoing enhancement of medical cost and utilization analysis and reporting across Medicare Advantage and Dual Eligible lines of business.
• Analyzes and interprets utilization and medical expense data; identifies key drivers including risk mix, Stars-related utilization, and site of care; performs drill-down analyses; and presents findings to leadership.
• Works with clinical, finance, and operations partners to ensure accurate capture, interpretation, analysis, and reporting of claims, encounters, and authorization data in alignment with CMS requirements.
• Supports enterprise trend management activities by monitoring emerging utilization and unit cost trends, identifying variance drivers against expectations, and partnering with clinical, finance, and operations leaders to inform mitigation strategies and performance management.
• PARTNERS WITH CLINICAL, FINANCE, OPERATIONS, AND OTHER TEAMS TO SUPPORT THE DELIVERY OF REGULATORY REPORTING, PROVIDER REPORTING, AND RELATED ANALYTIC REQUESTS, INCLUDING MEDICAID ADVANTAGE AND DUAL ELIGIBLE REPORTING REQUIREMENTS; ENSURE ANALYSES ARE ACCURATE, AUDITABLE, AND ALIGNED WITH CMS, INTERNAL GOVERNANCE, AND EXTERNAL STAKEHOLDER NEEDS.

Clinical Program Evaluation

• Drives the development of program metrics and outcomes during the design of new medical management, care management, and population health initiatives, particularly for Medicare Advantage and Dual Eligible populations.
• Designs and conducts analyses evaluating financial, utilization, quality, and clinical effectiveness of programs; interprets results and presents actionable insights to senior leaders.
• Collaborates with external vendors and delegated entities in analyzing outcomes of vended Medicare Advantage and Duals programs.
• Quantifies the impact of clinical and Stars-driven initiatives on medical expense trends and partners with finance and budgeting teams to incorporate results into forecasts and CMS bid support.

Overall

• DESIGNS AND EXECUTES COMPLEX QUERIES, EXECUTIVE-READY ANALYSIS, AND REPORTING IN SUPPORT OF AD HOC ANALYTICAL AND REGULATORY REQUESTS.
• DESIGNS, DEVELOPS, AND MAINTAINS AGILE AD HOC AND REPEATABLE REPORTING SOLUTIONS USING POWER BI, ENABLING BUSINESS PARTNERS TO INDEPENDENTLY EXPLORE DATA, MONITOR PERFORMANCE, AND CONDUCT MEANINGFUL COST, UTILIZATION, AND TRENDS ANALYSES WITH CONFIDENCE.
• ENSURES VALIDITY, ACCURACY, AND REPRODUCIBILITY OF ALL ANALYSES AND REPORTED INFORMATION.
• WORKS COLLABORATIVELY WITH IT AND DATA TEAMS TO ENHANCE AUTOMATION, ESTABLISH DATA STANDARDS, AND IMPROVE ANALYTIC INFRASTRUCTURE.
• ANTICIPATES INTERNAL CUSTOMER NEEDS, BUILDS TRUSTED RELATIONSHIPS, AND PROACTIVELY BRINGS FORWARD STRATEGIC MEDICAID ADVANTAGE AND DUALS INSIGHTS.