The VP of Actuarial IDFS (Integrated Delivery and Financing System) Advanced Analytics will lead a team of highly skilled experts that drive innovative activity across the health delivery enterprise. These activities include responsibility for the financial design, development and support of value based reimbursement programs across the health plan, advanced episode of care analytics to drive improved clinical performance and patient outcomes, and alignment of reimbursement initiatives across the enterprise. This position will lead efforts to bring together financial projection expertise from both AHN and HMK to create the next generation analytics and innovative reimbursement arrangements (transitioning from simple FFS to full risk spectrum) to effectively operate as an integrated delivery system.
Essential Job Functions:
- Perform management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity. Plan, organize, staff, direct and control the day-to-day operations of the department; develop and implement policies and programs as necessary; may have budgetary responsibility and authority.
- Conduct in-depth assessments to determine which interventional components drive the most enterprise value and make these components cost effective. Manage and coordinate across business unitsto bring HMK and AHN together for new analytic and purchasing opportunities for the IDFS:
Lead collaboration efforts to developing High Performing Network product of the AHN IDN, considering options for an HMO or EPO, and off-branded products
Provide necessary support for developing analytics that inform enterprise purchasing decisions on shared resource (e.g. pharmacy)
Coordinate and provide subject matter expertise in analytic design efforts that drive IDFS value (and revenue to the IDFS); could include optimization models
- Spearhead model development for the Pay for Value programs that are replacing traditional fee for service payment structures, including ROI analysis, savings models,risk models, MLR models, as well as continuous monitoring and updating to ensure that models are driving the value desired. Partner with provider and AHN leaders to drive the success of these programs by taking an active role in the development, vetting and continuous communication of the program data and analytics. Expand AHN risk-share models across other payers, including Government programs and other commercial carriers. This includes developing capitation packages and bundled payment programs with CMS and HMK Inc; also CMS ACO opportunities. Lead scenario planning modeling and competitive intelligence analytics efforts to provide input to contracting strategies.
- Develop financial analytics and models to help ensure appropriate and financially viable new IDFS programs and assets, including ROI modeling, capacity modeling, savings modeling, and physician program opportunity modeling.
Develop comprehensive models to predict the number of physicians (PCP and Specialist) that will be needed to bring a new asset to capacity. This will include operational aspects of VBR program at HMK for reporting, valuation, and forecasting. This includes the monthly actuarial estimate for finacial reporting of liabilities or accruals. Produce estimates for pricing impacts for use in client pricing/charge back or for use in setting fully insured premium rates.
- Perform ongoing due diligence and market intelligence gathering related to Healthcare Analytics, including monitoring of clinical groupers, predictive modeling and advanced analytic capabilities. Continually assess and contract for market differentiating groupers, predictive models, and analytic tools. Collaborate across AHN and HMK and provide clinical expertise from both perspectives to vet analytics to discover and promote "best practices". This will include, but is not limited to the development of customized solutions to episodic and diagnosis-based provider profiling analytics, incorporating the best-sources of data including Optum and Milliman.
- Create strategy for building or acquiring analytics that drive value by placing analytical and clinical tools on top of integrated administrative, EMR, practice management, mobile biometric monitoring and other data. The ability to transform analytical thinking to leverage integration of new and varied data types will be a key to differentiating Highmark in the market place. Create, maintain and support local analytics within AHN and provider systems. This will require a proactive facilitation within Actuarial Community of Practice to:
- Coordinate analyst interfaces with others in the community
- Support development of actuarial policies across Business Units
- Bachelor’s degree in Mathematics, Actuarial, Economics or related field
- ASA required
- FSA preferred
- 7-10 + years of experience in an actuarial role
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies
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