Manager, Medical Economics
Lead membership and premium reconciliation for a Medicare Advantage health plan serving older adults. Reconcile enrollment, eligibility, and capitation revenue across payer files and internal systems; investigate variances, recover at-risk revenue, and build scalable processes. Requires 7+ years healthcare analytics/medical economics experience, strong Excel, and managed care knowledge.
About the job
Key Responsibilities
- Lead the end-to-end membership reconciliation process, ensuring that enrollment, eligibility, and capitation payments are accurately tracked and reconciled across payer files, internal systems, and the general ledger.
- Investigate and resolve membership and premium variances, including retroactive additions, terminations, and rate changes.
- Quantify revenue at risk and collaborate with internal teams and health plans to recover discrepancies.
- Build and maintain business rules, controls, and data flows supporting member-month counts and premium accrual processes.
- Partner with Finance, Operations, and EIM teams to identify root causes and implement upstream data improvements.
- Produce monthly reconciliation reports and dashboards to give leadership visibility into membership, PMPM, and premium trends.
- Support month-end close activities by validating premium revenue and explaining membership and premium variances.
- Conduct independent analyses and present findings and recommendations to leadership.
- Design scalable reconciliation processes and prepare to support the growth of an analyst team.
Qualifications
Required
- Bachelor’s degree in Statistics, Mathematics, Economics, Computer Science, Healthcare Management, or a related field.
- 7+ years of experience in healthcare analytics, medical economics, or premium/membership reconciliation.
- Experience with healthcare, managed care, health plans, value-based care organizations, or healthcare analytics environments.
- Strong expertise in Medicare Advantage, healthcare analytics, and/or medical economics.
- In-depth understanding of healthcare financial concepts, including PMPM, member months, capitation, premium accrual, and eligibility.
- Experience with enrollment and eligibility data, including payer files such as 834/820 transactions.
- Advanced Excel proficiency and the ability to independently analyze complex datasets.
- Ability to present analytical findings and recommendations to leadership.
- Strong analytical, problem-solving, communication, and relationship-building skills.
Preferred
- Experience with SQL.
- Experience in premium reconciliation processes.
- Managed care organization experience.
- Experience building dashboards in Power BI or Tableau.
- Knowledge of value-based care analytics and risk-based reimbursement models.
- Previous leadership or team management experience.
Skills
SQL, Excel, Power BI, Tableau, Medicare Advantage, Healthcare Analytics, Medical Economics, Pmpm, Capitation, 834 Transactions, 820 Transactions
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