Medical Economist

A bit about this role:  The Medical Economist is a strategic and operational leader responsible for optimizing medical cost management, driving total cost of care (TCOC) strategy, and maximizing financial performance across Commercial lines of business. This role bridges high-level financial strategy and end-to-end operational execution by evaluating complex provider contract reimbursement models, partnering with technical and claims engineering teams to ensure accurate system configuration and adjudication, monitoring total medical expense (TME) trends, and delivering actionable intelligence to executive leadership. We place the highest value on proven real-world experience, problem-solving ability, and operational impact. While formal education and certifications are recognized, a strong track record of navigating complex Commercial healthcare economics, contract mechanics, and data-driven execution is what truly defines success in this role. Your Responsibilities and Impact will include: Strategic Contracting & Reimbursement Architecture Reimbursement Strategy & Design: Partner with Network Development and Contracting teams to design, model, and evaluate complex provider reimbursement structures across Commercial networks (e.g., FFS, DRG/APC, Ambulatory Payment Classifications, bundled payments, sub-capitation, and value-based risk agreements). Contract Evaluation & Financial Modeling: Conduct rigorous pre-contract modeling and scenario analysis for fee schedules, tiering, facility contracts, and alternative payment models (APMs) to quantify micro- and macro-financial impacts prior to execution. Commercial Risk & Value-Based Care: Oversee financial mechanics for Commercial value-based contracts, shared savings/risk arrangements, quality bonus pools, and provider incentive programs. Operations, Claims Configuration & Adjudication Alignment Technical Translation & Configuration Guidance: Collaborate directly with Claims, Health Plan Operations, and Engineering/IT teams to translate complex contract terms, fee schedules, and payment logic into actionable technical specifications. System Adjudication Assurance: Establish continuous testing, audit, and validation frameworks alongside Claims Operations and Payment Integrity to ensure claims adjudicate strictly according to contracted intent and configuration design. Leakage & Payment Integrity Oversight: Identify systemic claim adjudication defects, configuration errors, and unexpected cost leakage; drive end-to-end root-cause analysis and system remediation. Medical Cost Analytics, Trend Identification & Intelligence Commercial TME & Unit Cost Monitoring: Drive regular decomposition and reporting of Total Medical Expense (TME), isolating price (unit cost), utilization (volume), mix shifts, and intensity across inpatient, outpatient, professional, and pharmacy categories. Actionable Business Intelligence: Synthesize complex clinical, claims, authorization, and financial data into proactive business intelligence, pinpointing medical cost drivers and identifying actionable cost-optimization initiatives. Benchmarking & Market Dynamics: Perform competitive market benchmarks (e.g., relative to Medicare rates or regional commercial benchmarks) to identify fee schedule gaps, contracting leverage, and efficiency opportunities. Commercial Financial Mechanics & Forecasting Commercial-Specific Mechanics: Analyze and model commercial-specific cost drivers, including high-cost claimant spikes, ACA risk adjustment (HHS-HCCs), stop-loss/reinsurance recoveries, benefit design changes, and out-of-network leakage. Forecasting & IBNR Collaboration: Partner with Actuarial, Finance, and Underwriting teams to inform medical loss ratio (MLR) forecasting, IBNR reserve estimates, premium rate-setting, and employer group performance reporting. Clinical & Care Management ROI: Collaborate with Clinical Operations and Medical Management to evaluate the financial return on investment (ROI)