Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Director, Government Programs Integrity and Data Analytics

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Director and Equivalent
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190OV Requisition #
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Identify opportunities and execute programs to maximize CMS and SDOH revenue for the Medicare and State Sponsored programs while maintaining compliance with program requirements.  Through data analytics, identify opportunities to improve medical costs, quality performance, network performance, operational performance and execute programs to achieve financial targets. Oversee Government Programs Data Analytics team.  Work across the enterprise to support special revenue, medical and cost management related projects.

Responsibilities:
  • Using data analytics, work with business units to identify opportunities to improve revenue, operational performance, quality measure performance, contracting and provider performance, and to reduce medical costs.
  • Identify opportunities for more robust HCC capture to improve revenue
  • Compile, analyze, and report on diverse datasets to highlight revenue maximization opportunities.
  • Advocate for and facilitate data-based decision making at the leadership team and business / functional unit management level. 
  • Advise the business and functional leadership team on analytics value opportunities on an ongoing basis.
  • Develop strategies, and drive the execution of strategies, to improve revenue, operational performance, quality measure performance, contracting and provider performance, and to reduce medical costs.
  • Contribute to strategic discussions / market access planning processes to enhance the effectiveness of implementation of business and strategies.
  • Improve MLRs through the creation and deployment and tracking initiative through a management report dashboard. 
  • Analyze network performance and identify opportunities to improve network and provider performance across Government programs.
  • Drive initiatives to reduce unit cost, identify preferred providers, and develop strategies to for new payment models. 
  • Oversee SSP and Medicare recovery opportunities identified by Medical Economics. 
  • In collaboration with Medical Economics, ensures payment integrity and accurate provider reimbursement, identifies cost containment and recovery initiatives, maintains and publishes dashboard analytics, supports the development of trend forecasting and risk models, financial, operational, quality, and clinical optimization and improvement.
  • Ensures appropriate benefit configuration and coverage compliance for all Government products.
  • Oversee a team of data analyst who support the analytic and reporting needs of Government Programs across the enterprise.
  • Work with Medical Economics to develop and produce financial and operational dashboards.
  • Develop performance metrics to build transparency into operational and financial performance of Government Programs. 
  • Analyze results, identify opportunities, areas for improvement and strategies to optimize performance.
  • Supervise the direct reports and mentor the staff.
  • Build relationships with external regulatory agencies to facilitate identification and collection of Medicare underpayments including membership variances. 
  • Identify systematic payment breakdowns and execute solutions for retroactive financial recovery.
  • Oversee the Government Programs Project Management Team.
  • Regular attendance is an essential function of the job.  Performs other duties as assigned or required.
Qualifications:
  • Bachelor’s degree required
  • Masters degree preferred
  • Minimum of 10-12 years of relevant job experience required
  • Medicare and Medicaid Managed Care experience specifically the enrollment, payment and risk adjustment reconciliation methodology for both programs required
  • Strong Data manipulation and data analysis tools preferred

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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