Director, Reimbursement Analytics

Job Summary:

The Director, Reimbursement Analytics is responsible for leading the strategy, execution, and oversight of reimbursement analytics and policy across all lines of business, ensuring accuracy, compliance, and competitiveness of provider payment structures. This role directs a team in the development and maintenance of reimbursement methodologies, pricing models, and performance monitoring tools, while partnering closely with senior leadership, contracting, compliance, and configuration teams. The Director will play a key role in shaping reimbursement policy, supporting new market launches, and ensuring adherence to regulatory requirements at the state, federal, and contractual levels.

Essential Functions:

• Ensure provider reimbursement methodologies align with state, federal, and contractual requirements.
• Create and update custom fee schedules and alternative payment schedules.
• Identify gaps in reimbursement and develop competitive pricing strategies.
• Advise on and support the development of advanced reimbursement policy.
• Track and model the financial impact of state and federal rate adjustments.
• Ensure claims are priced accurately according to the correct methodology and benefit structure.
• Review and advise on standard and non-standard compensation language.
• Monitor state and federal reimbursement mandates and policy changes, ensuring timely alignment.
• Manage and develop Qualified Payment Amounts (QPA) for Marketplace.
• Identify and address non-compliant reimbursement practices
• Own regulatory reporting requirements that fall under Provider Contract Analytics.
• Develop and maintain dashboards for QPA, fee schedules, and default-to-%BC methodology.
• Track and design strategies to address pricing and billing irregularities.
• Monitor and support reimbursement strategies related to Single Case Agreements.
• Partner with business owners in new markets to ensure adherence to reimbursement policy.
• Ensure configuration of new markets and products aligns with contract language.
• Collaborate with IT and Compliance to ensure business and data requirements are met.
• Manage relationships with the configuration team to ensure accurate implementation of reimbursement policies.
• Advise and support the Enterprise Provider Reimbursement Committee (EPRC) with ownership of responsibilities and documentation.
• Organize and maintain a responsibility matrix for defining, designing, and implementing reimbursement policy.
• Perform any additional job-related duties as assigned by senior leadership.

Education and Experience:

• Bachelor's degree in finance, economics, computer science, healthcare management, or a related field or equivalent work experience is required.
• Master's degree in business, analytics, or a related field is preferred.
• Minimum of ten (10) years of experience in healthcare analytics, provider contracting, or financial analysis, with a focus on managed care.
• Minimum of five (5) years of management experience, including leading teams and managing cross-functional initiatives.
• Extensive experience in presenting data-driven insights and recommendations to senior leadership.
• Experience in Medicaid, Marketplace, and Dual-Eligible plan reimbursement highly preferred.

Competencies, Knowledge and Skills:

• Advanced proficiency in data analytics, including the use of SQL or other statistical software.
• Expertise in Microsoft Excel, including advanced data modeling and reporting capabilities.
• Proficiency in Power BI or other data visualization tools.
• Strong understanding of healthcare reporting standards and managed care principles.
• Strong leadership abilities with demonstrated experience in mentoring and developing high-performing teams.
• Excellent communication skills, with the ability to influence executive leadership and cross-functional stakeholders.
• Strong problem-solving and critical thinking abilities, with experience making data-driven decisions in high-pressure situations.
• Strong relationship-building skills and ability to work collaboratively across departments.
• Ability to manage multiple priorities and drive process improvement in a fast-paced environment.

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time. Occasional travel may be required for meetings with key providers or stakeholders

Compensation Range:
$132,900.00 - $232,700.00 CareSource takes into consideration a combination of a candidate's education, training, and experience as well as the position's scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee's total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type:
Salary

Competencies:
- Create an Inclusive Environment
- Cultivate Partnerships
- Develop Self and Others
- Drive Execution
- Influence Others
- Pursue Personal Excellence
- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.

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