Manager, Operational Analytics

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The Manager, Operational Analytics will collaborate closely with the Director, Operational Analytics, as well as other colleagues, across product, operations, medical management, and provider contracting to support and implement high-quality, data-driven decisions. The ideal candidate will be the subject matter expert for both Commercial and Government Programs data and analytics. They will ensure data accuracy and consistent reporting by designing, creating optimal processes and procedures for analytics employees to follow. They will use advanced data modeling, predictive modeling, and analytical techniques to interpret key findings from company data and leverage these insights that will help us design, build, and manage our health plan.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Business Administration, Finance, Mathematics, Computer Science, Statistics, Information Systems, or a related field.

EXPERIENCE:

1. Six (6) years of experience monitoring, managing, manipulating, and drawing insights from data in a managed care company.

2. Three (3) years of experience working with claims data to evaluate reimbursement changes, payment discrepancies, medical expense opportunities, quality outcomes and risk.

3. Foundational understanding of health plan economics and financial drivers.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Business Administration, Computer Science, Statistics, Information Systems, or a related field.

2. Experience working in an analytic capacity collaboratively with Medical Economics, Risk Adjustment, Quality, Actuarial or Finance functions within an insurer focused in Government/Commercial products. 

3. Experience with Medicare and/or Medicaid Regulatory Reporting.

4. Foundational understanding of prescription drug programs.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Assist with development of the monthly data loads for our various analytics vendors, such as HEDIS and risk adjustment, in-home assessments, lab kit and payment integrity vendors.

2. Acts as subject matter expert who maintains up-to-date knowledge and interpretation of applicable regulations, CMS guidelines and requirements, and Medicare models.

3. Establish and lead the data collection operation and process plans for the HEDIS and Risk Adjustment analytics tool. Work with the HEDIS and Risk Adjustment analytics vendor to ensure data we send to vendor aligns with requirements. Knowledge of the data needed to close gaps in care is essential.

4. Lead the analyst team assisting with the Stars Program strategy, objectives, and initiatives through the creation of reports and/or analysis

5. Assist with the data aspects of a HEDIS program audit. Collaborate with the HEDIS Program Manager to answer any questions posed by the Plan’s NCQA-certified HEDIS auditor.

6. Assist with implementation of electronic record retrieval integration, including developing and maintaining relationship with electronic record retrieval vendor.

7. Identify data that could potentially help the Quality Department impact HEDIS rates.

8. Possess knowledge of Medicare Part C and D regulatory reporting to include, but not limited to, Supplemental Benefit Utilization and Cost, Organization Determinations/Reconsiderations, Grievances, Enrollment/Disenrollment, and Payments to Providers.

9. Support the submission of the Prescription Drug Data Collection (RxDC) Reporting suite of regulatory reports for employer-sponsored group health plans.

10. Knowledge of regulatory reporting includes inbound/outbound CMS data requirements, data specifications, laws and regulations, and any changes to current or future regulations. Produce regulatory reports on a quarterly cadence.

11. Create data files for other vendors such as our in-home assessments, lab kits, and payment integrity vendors.

12. Proactively work to identify and remedy any data integrity issues that may impact the accuracy of HEDIS and Risk Adjustment analytics. Keep the team informed of any impact this could have on HEDIS and Risk Adjustment analytics output.

13. Support the regulatory reporting strategy, objectives, and initiatives through the creation of reports and/or analysis to drive efficiency for the Plan.

14. Work with business leader(s) to develop and execute regulatory reporting roadmap that defines the path to operationalize specific actions which are repeatable, measurable, and cost-effective.

15. Work cross functionally with the actuarial team to support repricing analysis, and underwriting.

16. Support analysis of product performance, including but not limited to drivers of trend and assist in the development of reporting packages.

17. Support the Business Intelligence Engineers in the development of reports and dashboards to give business units visibility into the data they need to make business decisions.

18. Build, develop and maintain data models, reporting systems and performance metrics to support key business decisions.

19. Design and build technical processes in conjunction with IT for data migration across applications.

20. Anticipates future demands of initiatives related to people, process and technology and works with leadership to design and implement solutions to these needs

21. Provide subject matter expertise, support, and training, as needed, for business units responsible for daily operations. Ability to work collaboratively across many teams, prioritize demands from those teams, synthesize information received, and generate meaningful conclusions.

22. Work closely with Quality, Risk Adjustment, Analytics, Finance, Actuarial, Provider Networking/Relations, and other teams within the company to execute on business objectives.

23. Support the development, integration, and maintenance of regulatory reporting initiatives. Ensure efficiency in creating regulatory reports on specified cadence.

24. Ensure compliance with all applicable regulatory requirements, guidelines, and contractual obligations set forth by CMS.

25. Prepare and submit regulatory reports to Compliance Department for submission to CMS by date specified in CMS regulations.

26. Performs other duties as assigned.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Working on a computer.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Remote.

2. Standard Office Environment.

SKILLS AND ABILITIES:

1. Strong programming skills with query languages such as SQL and the ability to perform effective querying from multiple tables and databases.

2. Experience with querying tools such as SAS, Microsoft SQL Server Management Studio, and Power BI.

3. Experience with data visualization tools such as Tableau.

4. Experience working with Oracle, Teradata, Hadoop, etc.

5. Strong problem solving and quantitative abilities.

6. Excellent communication and collaboration skills.

7. Attention to detail.

8. Working knowledge of claims, utilization management, member, and/or provider data.

9. Strategic thinking.

10. Effective time management and organizational skills.

11. Work independently as well as in a team environment.

12. Proficient computer skills, including experience with Microsoft Office Suite such as Excel functionality (pivot tables, vlookups, macros, etc.)

13. Familiarity with HEDIS, CAHPS, PQA/Pharmacy, HOS, and CMS Display measures and/or other health care quality metrics.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2903 PHH Operational and Provider Analytics