Medical Economist

Overview

A Medical Economist role is available for a strategic and operational leader focused on optimizing medical cost management, driving total cost of care (TCOC) strategy, and improving financial performance across Commercial lines of business.

This position connects financial strategy with end-to-end execution by evaluating complex provider contract reimbursement models, partnering with technical and claims engineering teams to support accurate system configuration and adjudication, monitoring total medical expense (TME) trends, and delivering actionable insights to executive leadership.

Responsibilities

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, including FFS, DRG/APC, Ambulatory Payment Classifications, bundled payments, sub-capitation, and value-based risk agreements.
• Contract evaluation & financial modeling: Perform pre-contract modeling and scenario analysis for fee schedules, tiering, facility contracts, and alternative payment models (APMs) to quantify micro- and macro-financial impacts before 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 with Claims, Health Plan Operations, and Engineering/IT teams to translate contract terms, fee schedules, and payment logic into technical specifications.
• System adjudication assurance: Build and maintain testing, audit, and validation frameworks to ensure claims adjudicate strictly according to contracted intent and configuration design.
• Leakage & payment integrity oversight: Identify claim adjudication defects, configuration errors, and unexpected cost leakage; lead root-cause analysis and remediation.

Medical Cost Analytics, Trend Identification & Intelligence

• Commercial TME & unit cost monitoring: Drive 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: Combine clinical, claims, authorization, and financial data to identify medical cost drivers and recommend cost-optimization initiatives.
• Benchmarking & market dynamics: Conduct competitive market benchmarks (including 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: Model commercial 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 for medical loss ratio (MLR) forecasting, IBNR reserve estimates, premium rate-setting, and employer group performance reporting.
• Clinical & care management ROI: Work with Clinical Operations and Medical Management to evaluate ROI and medical cost reduction impacts of disease management, utilization management, and population health initiatives.

Executive Leadership & Cross-Functional Collaboration

• Executive presentation: Deliver executive summaries, monthly/quarterly financial trend packages, and strategic recommendations to market leadership, the CFO, and cross-functional steering committees.

Requirements

• Experience: 8+ years of hands-on, progressive experience in healthcare economics, managed care finance, or healthcare data analytics, including 3–5 years focused on Commercial lines of business (Individual/ACA, Group, ASO/Self-Funded).
• Reimbursement expertise: Strong, practical knowledge of Commercial reimbursement methodologies, including Commercial Fee-for-Service schedules, Medicare-relative pricing, DRGs, CPT/HCPCS, Revenue Codes, APCs, ASC fee schedules, stop-loss, and Commercial risk adjustment.
• Contract-to-claims execution: Demonstrated track record evaluating provider contract language, modeling reimbursement shifts, and collaborating with IT/claims teams to guide configuration and ensure accurate claim adjudication.
• Technical & analytical proficiency: Ability to query, manipulate, and analyze large healthcare claims datasets using SQL, Python, R, SAS, or modern cloud data warehouses.
• Cross-functional leadership: Proven ability to lead cross-functional initiatives and align priorities across Network, Claims, Operations, Engineering, Finance, and Actuarial teams.
• Strategic communication: Ability to synthesize complex claims and financial data into plain-language insights and present actionable recommendations to executive leaders.

Preferred Qualifications

• Value-based care execution: Experience designing, evaluating, or managing Commercial ACO models, bundled payment structures, and shared risk/savings arrangements.
• Regulatory navigation: Practical understanding of Commercial regulatory environments, including state insurance mandates, ACA guidelines, ERISA, and the No Surprises Act (NSA).
• Dual payer/provider perspective: Experience working directly within health plan operations, health systems, or provider organizations navigating managed care contracts.
• Education/credentials (optional): Actuarial credentials (ASA/FSA) or advanced degrees (Master’s/MBA).

Compensation & Benefits

• Salary range: $175,000–$250,000 per year.
• Employer-sponsored health, dental, and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• Additional total rewards details apply (e.g., eligibility for full-time employees only).

Location

Location information was not provided in the posting.