Director, Health Plan Economics

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

Overview of the Role:

The Director of Health Plan Economics will supervise, review and manage the development and implementation of the Alignment Provider Management Report (APMR). This will include the design and development of ad hoc reports to support Provider Contracting and Network Development, analysis of product line profitability, gross margin, and expansion market analytic support. Another focus area will be creating, managing and distributing monthly, quarterly and annual risk pool exhibits to delegated entities/IPAs. This involves cross functional work with departments such as network management, claims, utilization management, provider configuration, IT, etc. in interpreting contracts, updating claims data to factor in exclusions for out of area services, transplants, etc. and assisting delegated entities as well as internal stakeholders in risk pool changes over time (identifying key drivers of risk pool surplus or deficits).

Responsibilities:

• Develop and manage Alignment Provider Management Report (APMR) for current and expansion markets.
• Work with Alignment IT department to assist in the programming and mapping of various financial and key performance indicators within APMR
• Work with Alignment Accounting staff to reconcile and verify the integrity of APMR yearly and monthly financial data to the General Ledger
• Work with Alignment FP&A team to incorporate budget data and assumptions into APMR.
• Work with Alignment Claims department to validate the integrity of claim payment within APMR
• Work with Alignment Provider Contracting and Network Development staff to analyze contract rate trending impact and anomalies.
• Work with Alignment UM and Clinical operations department to validate and reconcile key authorization admit and bed day metrics to actual paid claim data.
• Support Regional VP’s in providing analysis of monthly APMR data and ad hoc reporting of key performance indicators.
• Support finance and operations in developing predictive KPI’s to better forecast and manage the business of Alignment.
• Plan, prioritize, assign, supervise and review the work of staff responsible for providing APMR services.
• Provide or coordinate staff training as necessary; work with employees to correct deficiencies; implement discipline procedures.
• Work with all levels of staff to direct, assist, and explain the APMR process as needed.
• Demonstrate commitment and attendance sufficient to complete the duties of the position as required.
• Perform related duties similar to the above in scope and function as required.

Required Skills and Experience:

• At least 10 years of experience in financial/data analysis.
• At least 5 years of managerial experience
• Education/Licensure: Bachelor of Science in Business preferred
• Other:
• Knowledge of principles and practices of finance administration in accounting, budgeting, and auditing.
• Understanding of CMS Premium payment methodologies to MA Health Plans. Understanding MMR documentation, premium payment calculations, Risk adjustment Factors (RAF), other premium adjustments, and file layout.
• Understanding of CMS provider payment methodologies (DRG, RBRVS, etc.)
• Understanding of operations, services and activities within a Data Warehouse environment (Claim Data, Membership, Eligibility, and Revenue Data, etc.)
• Understanding provider capitation contracts, development of capitation rates, contract carve outs, performed comparative analysis to Fee For Service.
• Exposure and ability to use Actuarial studies related to IBNR and LDS
• Understanding of provider contracts for medical groups, independent physicians, and hospitals.
• Understanding of payment methodologies for Hospitals (DRG, Per Diem, % of Billed, etc.) and Physicians (RBRVS, FFS, Capitation, etc.) and other ancillary providers.
• Develop new analysis and approaches to the use of data that allow fresh insights into the business of the company
• Be able to work to goals with low level of supervision
• Communicate clearly and concisely, both orally and in writing.
• Establish and maintain effective working relationships with those contacted in the course of work.
• Maintain effective audio-visual discrimination and perception needed for making observations; communicating with others; reading and writing; and operating assigned equipment.
• Maintain mental capacity which allows the capability of making sound decisions and demonstrating intellectual capabilities.

Pay Range: $160,000 - $180,000 annually.

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

• DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.