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Director, Healthcare Economics, Risk Adjustment & Regulatory Reporting

Overview

Oversees the Healthcare Economics and Regulatory Reporting units for VNSNY CHOICE. Establishes the strategic direction for the unit which supports operational, financial, quality, risk adjustment and clinical optimization and improvement, development of forecasting models, and medical and risk management. Investigates and identifies areas for membership growth, medical expense management, revenue expansion, affordability and quality improvement. Ensures that CHOICE uses all available data assets to support analyses and improve business performance and appropriate inferences are made to guide leadership and management decisions. Works under limited direction.


Responsibilities
  • Collaborates with senior leadership to identify areas for empirical investigation and analysis of medical and economic trend performance of CHOICE programs and operations. Provides tactical guidance in VNSNY CHOICE’s development of healthcare economics utilization and unit cost trend, risk adjustment analytics and quality analytics dashboard reporting. Identifies opportunities and risks supported by data.  Formulates analytic design and methodology; applies statistical methods and analyses where relevant, and investigates and utilizes industry metrics where available.  Analyzes performance compared to industry or industry-proxy indicators.
  • Leads risk adjustment, quality and regulatory data submissions for CHOICE and ensures that risk adjustment, quality, and other regulatory data submissions for CHOICE products are timely and accurate. 
  • Leads the continuous improvement of the efficiency and accuracy of risk adjustment, quality, and other regulatory data submissions by CHOICE and its delegated vendors.
  • Coordinates with Business Intelligence team to design, validate and oversee the deployment of product dashboards to ensure that they address business needs.  Assesses the use and value of dashboards; produces design revisions as necessary to maintain alignment with business.  Coordinates with product and executive leadership to incorporate production dashboards into business processes; provides training as necessary.
  • Coordinates across business on consistent use of nomenclature and metrics across analysis and reporting, including documentation of methods and business rules.  As new groups are acquired or created, work with those teams to standardize and integrate data flows, processes and analytics.
  • Oversees the CHOICE data governance processes and participates as a data steward where necessary. 
  • Oversees and/or conducts testing to ensure corporate IT and outside vendors meet requirements for timely and accurate data delivery and regulatory data submissions.
  • Coordinates with various departments to ensure underlying data shown in reporting and used in analysis are accurate and complete.  Ensures data presented to end users via analytic products has been validated and accurately reflect business rules and definitions.
  • Identifies inconsistencies related to data systems and data capture; assists business or data processing departments to correct inconsistencies related to data systems and data capture.
  • Remains abreast of NYS and Federal policies for manged care health plans; anticipates and informs leadership with analytic insights regarding potential impact on CHOICE businesses.
  • Coordinates with VP to ensure department organization and staffing reflect business needs for medical economics and regulatory reporting.  Proposes and implements corrective actions as necessary.
  • Coordinates with technology, innovation, or other teams across the business to identify analytic tools or technologies to improve efficiency and effectiveness of department.  Conducts, presents, and defends ROI analysis for recommended actions.
  • Performs all duties inherent in senior managerial role.  Approves staff training, hiring, promotions, termination and salary actions; prepares and ensures adherence to the department budget. 
  • Participates in special projects and other duties as assigned.

Qualifications

Education:  Bachelor’s degree in Business, Health Administration, Health Policy or related discipline required.  Master’s degree in Business, Health Administration, Health Policy or related discipline preferred.

Experience:  Minimum seven years of managed care and professional level experience performing a broad range of healthcare insurance plan data analysis and management required.  Knowledge of HEDIS/Stars Program required. Strong managerial skills, and able to manage multiple teams required.    Experience working directly with and presenting to Executive management required.  Advanced proficiency in conducting financial and analytic analysis and modeling required.  Proficiency in SQL DML and analytic functions required.  Proficiency in use of data manipulation tools other than SQL required.  Experience with analytic data products required. Knowledge of health care data required.  Knowledge of health plan financial and regulatory reporting standards required. Experience with the following applications preferred: Oracle, PL/SQL, SQL Server, SQL Server Reporting System, R, Python, Microstrategy.

CA2020


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ABOUT US

The Visiting Nurse Service of New York (VNSNY) is the nation's largest not-for-profit home- and community-based health care organization, serving the five boroughs of New York City, and Nassau, Suffolk, and Westchester Countries. For over 125 years, VNSNY has been committed to improving the health and well-being of people through high-quality, cost effective healthcare in the home and community. We offer a wide range of services, programs, and health plans to meet the diverse needs of our patients, members, and clients from before birth to the end of life. Each day, more than 13,000 VNSNY employees - including nurses, rehabilitation therapists, social workers, other allied professionals, and paraprofessionals - deliver compassionate care, unparalleled medical expertise, and 24/7 solutions and resources to more than 44,000 patients and members, helping them to live the best lives possible in their homes and communities.