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Analytics Lead - Medical Economics, Medical Expense Review

Primary Location: Plano, TX
Additional Locations: FL-Fort Myers, TX-Dallas, TX-Houston, TX-Plano
Manages and develops provider reimbursement programs, policies, and strategies to ensure unit cost controls meet or exceed corporate objectives for medical cost containment. Provides analytical support critical in positioning system or network changes necessary to enhance market share, competitive position.

Fundamental Components:
Oversees development and implementation of market specific provider compensation and reimbursement schedules, regional recovery process and Network Information System Support (NISS). Oversees the production of both standard and ad-hoc reports used for risk assessment analysis, budgeting, and hospital chargemaster analysis and forecasting. Partners and consults with Actuarial, Network, Patient Management and Segment teams to provide medical cost analysis to assess effectiveness of managing costs creating and implementing plans to effectively manage medical costs based on analysis or trends. Provides hospital and physician contract audit and review support (i.e., provider practice analysis, BIR support). Conducts stop loss reviews and supports overpayment and recovery efforts. Coordinates rate approvals and develops pricing for most complex contractual arrangements. Develops tactical and strategic plans to satisfy information needs across products, segments and markets.

Background Experience:
Knowledge of market-place delivery (understanding of provider relationships.)Understanding of internal and external database applications.Advanced communication/presentation skills.Full comprehension of provider contracts and the potential impact the regulatory/legislative environment has on reimbursement strategies.Extensive knowledge of managed care and how provider reimbursement policies relate to the control of medical claims costs.Minimum of 6+ years' experience in a health care delivery systems role with accountability for business results. Bachelor's Degree in Business, Finance or a related field required.Advanced degree preferred.

Required Skills:
General Business - Communicating for Impact, General Business - Demonstrating Business and Industry Acumen, General Business - Turning Data into Information

Desired Skills:
General Business - Applying Reasoned Judgment, General Business - Ensuring Project Discipline, General Business - Maximizing Work Practices

Functional Skills:
Information Management - Medical economics, Information Management - Provides very complex programming and analytical support for medical cost trend analysis and strategic planning, Information Management - Utilizes and maintains pricing models and medical cost tracking tools

Technology Experience:
Database - Microsoft Access, Desktop Tool - Microsoft PowerPoint, Desktop Tool - TE Microsoft Excel

Potential Telework Position:

Percent of Travel Required:
10 - 25%

EEO Statement:
Aetna is an Equal Opportunity, Affirmative Action Employer

Benefit Eligibility:
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.

Candidate Privacy Information:
Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.

Click To Review Our Benefits (PDF)


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