The Finance Manager - will assist the Director of Finance, Managed Care by acting as primary backup in all functions related to financial operations. The Manager will actively participate in all financial reporting functions, budget development, analysis of operating results, inter-departmental consulting on establishment of benchmarking and measurement and other duties as assigned.

JOB FUNCTIONS

Essential job duties:

Identifying medical cost trends and participation in medical cost improvement initiatives.
Responsible for implementing CMS, DHCF, and DISB requirements related to medical loss ratio reporting, fiscal soundness reporting, audit assistance, and analysis of service utilization, drug utilization, and other cost trends. Participate in all internal and external reporting activities.
Participate in rate-setting activities by assisting the Director of Finance in the coordination of activities with DHCF and its consulting actuary.
Provide insight and analysis with respect to provider contracting and data analytics activities. Support Provider Relations business unit with the development of financial payor models and benchmark comparisons to support contractual decisions, including assumptions, observations, conclusions, and recommendations.
Plan, develop, and prepare complex reimbursement models, including but not limited to value-based payment and reimbursement, population health management, risk, and capitation to determine payor contract proposed terms.
Review and analyze statistical, cost, and financial reports for complex payor contracts.
Conduct retrospective review of claims payment history (Lag Report, PM/PM Report).
Monitor the volume of monthly authorizations and provide projections on the potential financial impact
Validate accuracy capitation revenue payments and reconcile with available sources, including QNXT, 820, and 834 files.
Keep abreast of financial and regulatory matters affecting managed care services. Take all reasonable steps to ascertain that the company conforms to applicable federal and local laws and regulations relating to financial issues.
Participate with Finance Director in establishing organizational and departmental performance metrics. Review performance against those benchmarks and implement corrective action plans as necessary.
Review monthly performance and financial results of the business unit and provide recommendations to senior management. Design and implement analytical financial dashboards of the health plan performance.
Regularly review historical operating results and proactively identify and analyze potential revenue enhancement and cost-saving opportunities.
Work with the Director of Finance and external parties in planning, review, and execution of annual year-end audits.
Responsible for special projects assigned to him/her by the Director of Finance.

Other job duties:

May perform other duties in addition to those outlined in this job description.

QUALIFICATIONS:

Required Experience:

Ten or more years of health care financial management experience with managed care experience preferred. Technical/Functional expertise: Medicaid and Managed Care Organization operations, Data Analysis/Business Intelligence, Strategic Planning, Strategic Contracting, Contract Negotiation, Financial Management, Project Management.

Current with knowledge of and experience in dealing with all aspects of integrated business models:

Minimum of five (5) years in a finance role(s) preferably in a Medicaid managed care plan
Experience with developing and preparing complex provider reimbursement models, including alternative payment models
Experience with developing and reviewing statistical, cost, and financial reports for complex payor contracts
Experience with financial data analysis and development of financial/accounting/executive dashboards. Ability to apply data and analytics to solve complex problems
Familiarity with federal and local financial and regulatory matters affecting managed care services
Proficiency with Excel, experience with Microsoft Management Studio, SQL or other database languages preferred
Excellent interpersonal and relationship management skills.
Excellent oral, written and presentation skills
Strong knowledge and/or aptitude for Business Intelligence software and major enterprise systems.