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Total Medical Expense

2 months ago

Worcester, United States Fallon Health Full time
Overview

About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief summary of purpose:

Primary responsibilities include identification, evaluation, implementation, and prioritization of initiatives to manage company medical expense by managing the portfolio of the Total Medical Expense Committee. This role facilitates cost containment initiatives across all lines of business with significant attention to ROI. Responsible to provide expert knowledge of development methodology approaches, techniques and tools to senior management, project managers, program teams and project teams.

Responsibilities also include facilitating vendor contract review and aid in negotiations of vendor contracts, specifications, and financial conditions for vendor contracts. Ensures adherence to Program plans and schedules and develops solutions to Program and project challenges. This position has a significant focus on the skill and diplomacy/tact required in working across functional areas and external organization to ensure initiatives are progressing as planned. These projects are directly related to optimizing cost of care and are multifunction and may be multi-year in scope.

Responsibilities

Primary Responsibilities:

Project Portfolio Planning:
  • Facilitates planning sessions for annual initiative development and for prioritized initiatives.
  • Supports identification, evaluation and prioritization of Medical Expense cost drivers.
  • Drives prioritization process of TME portfolio initiatives.
  • Supports the development with business owners of opportunity analysis including actuarial evaluation.
  • Ensures that all pending actuarial validations of pipeline initiatives and all appropriate savings to date are available to committee prior to each committee meeting.
  • Participates in analytical review of savings opportunities.
  • Participates in the actuarial assessment of Cost of Care initiatives.

Project Portfolio Oversight:
  • Supports the development, implementation, and measurement of cost of care programs initiatives.
  • Prioritizes and supports allocation of available project and/or program resources; to ensure goals and objectives of the cost of care initiatives are met.
  • Facilitates the identification of best approach(s) across Payment Policy, Unit Cost, Utilization, or Benefits to achieve maximum Medical Cost reduction for prioritized cost drivers.
  • Prepares and presents regular reports to the CFO, Division Presidents of HealthCare Operations, and appropriate medical cost monitoring committees.

Project Execution:
  • Demonstrates influencing skills in managing team members, stakeholders, and senior leadership.
  • Develops and maintains strong partnerships with management at all levels of one or more business units. Shares in the responsibility to achieve cost of care objectives.
  • Provides timely and effective communication of project status and key milestones to all stakeholders.
  • Ensures appropriate reporting is available for each Cost of Care Committee meeting. This reporting will, at a minimum, include key cost drivers and key metrics.
  • Utilizes Project Management Office (PMO) standard documentation materials and overall PM methodology as needed.
  • Insures accurate and timely reporting of key metrics; initiative specific reporting, and ad hoc reporting necessary to manage the cost of care.
  • Plans and manages monthly cost of care meetings.
  • Facilitates contract review and aid in negotiations of contracts, contractual changes, specifications, and financial conditions of vendor contracts.
  • Identify potential risks related to initiatives and outline strategies for mitigating them.

Guides and develops others:
  • Supports business owners in developing and tracking outcomes/success metrics.
  • Utilizes, contributes to, and trains others on Project Management methodology.
  • Perfroms other duties as assigned


Qualifications

Education:

Bachelor's: Accounting, Finance, Business Administration, or related field

License/Certification:

Project Management certification preferred, not required

Experience:
  • Requires demonstrated skill in leading cross-functional teams.
  • Requires 5+ years of project management experience or equivalent in the field or in a related area.
  • Relies on extensive experience and judgment to plan and accomplish goals. Experience in analyzing and utilizing data to drive business decisions.
  • At least 8 years' experience in healthcare analysis and/or management.
  • Knowledge of physician group, hospital, ambulatory, and health care administration within an integrated system-based delivery organization.
  • Proficient in Microsoft Windows based office applications to include MS Project, Excel, Word, PowerPoint, Visio, and SharePoint.
  • Strong verbal and written communication skills
  • Build Relationships - Relates to people in an open, friendly, accepting manner; initiates and develops relationship with others as a key priority; treats others with respect; is approachable.
  • Presentation Skills - Effective in a variety of formal presentation settings: one-on-one, small, and large groups, with peers, subordinates, and bosses; speaks effectively.
  • Works Efficiently - Allocates own time efficiently; handles multiple demands and competing priorities; eliminates inefficiencies; conducts effective meetings.
  • Lean Six Sigma green belt or above certification preferred, not required

Resources (systems, etc.) used in performing role:

QNXT, Trucare,InterQual, MS Office (Excel, MS Word, Outlook, PowerPoint), Electronic Medical Resources (PubMed)

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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