Job Description
Summary: The Medical Economics Analyst is responsible for analyzing healthcare cost, utilization, and financial performance to support value-based care strategies and optimize medical spend. This role leverages claims data, statistical methods, and financial modeling to develop actionable insights, evaluate program effectiveness, and inform pricing, capitation analysis, and reimbursement decisions. The analyst collaborates closely with finance, actuarial, network management, and clinical teams to drive data-driven strategies that improve quality outcomes and control costs.
Duties & Responsibilities: - Perform monthly and quarterly capitation reconciliation, including validation of eligibility rosters, retroactive member adjustments, and payment true-ups.
- Perform detailed analyses of Per Member Per Month (PMPM) costs, Medical Loss Ratio (MLR), and service category utilization across all lines of business.
- Develop standardized data extracts and reporting outputs to support in rate setting (pricing), forecasting, and modeling the financial impact of capitation.
- Conduct root cause analyses of medical cost trends and performance variances, identifying key drivers and actionable insights.
- Design, build, and troubleshoot complex SQL queries to aggregate, normalize, and validate data from multiple claims sources.
- Collaborate with Data Engineering, Actuarial, and Finance teams to ensure data accuracy, consistency, and alignment of definitions across reporting platforms.
- Create dashboards and summary reports using tools such as Power BI, Tableau, or Amazon QuickSight to communicate findings to stakeholders.
- Analyze utilization and cost trends across visits, admissions, and paid vs. allowed amounts to inform strategic planning and program evaluation.
- Identify high-cost members, outlier claims, and underperforming providers contributing to adverse cost or utilization trends.
- Evaluate and monitor PMPM costs by line of business, product, provider group, and geography.
- Calculate and interpret Medical Loss Ratio (MLR) using claims paid and premium revenue data.
- Compare performance outcomes of capitation versus fee-for-service payment models, including cost, utilization, and quality metrics.
- Generate insights and recommendations to support network optimization, including identification of high-cost providers or services requiring targeted interventions.
- Leverage tools such as Power BI, Tableau, Python, R, or SAS to perform data validation, statistical analysis, predictive modeling, and development of advanced analytics solutions
Requirements & Qualifications: - Bachelor’s degree in finance, Economics, Statistics, Public Health, Data Science, Health Administration, or a related field and or 3+ years of experience in healthcare analytics, medical economics, or actuarial analysis.
- Proficiency in SQL for working with large datasets.
- Experience with healthcare claims data, including 837 institutional and professional files.
- Skilled in data visualization tools such as Power BI, Tableau, or QuickSight.
- Working knowledge of Python, R, or SAS for analysis and modeling a plus.
- Experience analyzing PMPM costs, MLR, utilization, and cost trends.
- Familiarity with reimbursement models like fee-for-service, case rate, per diem and capitation.
Competencies: - SQL: Build and optimize queries for data extraction and validation.
- Data Analysis: Use Python, R, or SAS to analyze trends and metrics.
- Data Visualization: Create dashboards in Power BI, Tableau, or QuickSight.
- Claims Data: Work with 837 institutional and professional files.
- Healthcare Metrics: Calculate PMPM, MLR, and utilization rates.
- ETL: Understand data integration and transformation processes.
- Data Quality: Validate and clean datasets for accuracy.
- Reporting: Automate and standardize reports.
- Documentation: Clearly document methods and results.
- Communication, Oral - Ability to communicate effectively with others using the spoken word.
- Communication, Written - Ability to communicate in writing clearly and concisely.
- Proactive Client Management - Ability to take care of the customers’ needs while following company procedures.
- Interpersonal - Ability to get along well with a variety of personalities and individuals.
- Problem Solving – Ability to find a solution for or to deal proactively with work-related problems.
- Relationship Building - Ability to effectively build relationships with customers and co-workers.
- Working Under Pressure - Ability to complete assigned tasks under stressful situations.
Job Tags
Daily paid, Full time,