Medical Economist

Job Description

A bit about this role:

The Medical Economist is a strategic and operational leader responsible for optimizing medical cost management, driving total cost of care (TCOC) strategy, and maximizing financial performance across Commercial lines of business.

This role bridges high-level financial strategy and end-to-end operational execution by evaluating complex provider contract reimbursement models, partnering with technical and claims engineering teams to ensure accurate system configuration and adjudication, monitoring total medical expense (TME) trends, and delivering actionable intelligence to executive leadership.

We place the highest value on proven real-world experience, problem-solving ability, and operational impact. While formal education and certifications are recognized, a strong track record of navigating complex Commercial healthcare economics, contract mechanics, and data-driven execution is what truly defines success in this role.

Your Responsibilities and Impact will include:

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 (e.g., FFS, DRG/APC, Ambulatory Payment Classifications, bundled payments, sub-capitation, and value-based risk agreements).
• •Contract Evaluation & Financial Modeling: Conduct rigorous pre-contract modeling and scenario analysis for fee schedules, tiering, facility contracts, and alternative payment models (APMs) to quantify micro- and macro-financial impacts prior to 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 directly with Claims, Health Plan Operations, and Engineering/IT teams to translate complex contract terms, fee schedules, and payment logic into actionable technical specifications.
• •System Adjudication Assurance: Establish continuous testing, audit, and validation frameworks alongside Claims Operations and Payment Integrity to ensure claims adjudicate strictly according to contracted intent and configuration design.
• •Leakage & Payment Integrity Oversight: Identify systemic claim adjudication defects, configuration errors, and unexpected cost leakage; drive end-to-end root-cause analysis and system remediation.

Medical Cost Analytics, Trend Identification & Intelligence

• •Commercial TME & Unit Cost Monitoring: Drive regular 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: Synthesize complex clinical, claims, authorization, and financial data into proactive business intelligence, pinpointing medical cost drivers and identifying actionable cost-optimization initiatives.
• •Benchmarking & Market Dynamics: Perform competitive market benchmarks (e.g., 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: Analyze and model commercial-specific 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 to inform medical loss ratio (MLR) forecasting, IBNR reserve estimates, premium rate-setting, and employer group performance reporting.
• •Clinical & Care Management ROI: Collaborate with Clinical Operations and Medical Management to evaluate the financial return on investment (ROI) and medical cost reduction impact of disease management, utilization management, and population health initiatives.

Executive Leadership & Cross-Functional Collaboration

Executive Presentation: Prepare and deliver high-impact executive summaries, monthly/quarterly financial trend packages, and strategic recommendations to market leadership, the CFO, and cross-functional steering committees.

Required skills and experience:

(Hands-on experience, execution ability, and proven performance take precedence over formal degrees or professional credentials).

• •Core Industry Experience: 8+ years of hands-on, progressive experience in healthcare economics, managed care finance, or healthcare data analytics, with at least 3–5 years focused specifically on Commercial lines of business (Individual/ACA, Group, ASO/Self-Funded).
• •Applied Reimbursement Expertise: Deep, practical knowledge of Commercial reimbursement methodologies (Commercial Fee-for-Service schedules, Medicare-relative pricing, DRGs, CPT/HCPCS, Revenue Codes, APCs, ASC fee schedules, stop-loss, and Commercial risk adjustment).
• •End-to-End Contract-to-Claims Execution: Demonstrated track record of evaluating provider contract language, modeling reimbursement shifts, and actively collaborating with IT/claims teams to guide configuration and ensure accurate claim adjudication.
• •Technical & Analytical Proficiency: Direct, hands-on ability to query, manipulate, and analyze large healthcare claims datasets using tools like 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: Strong ability to synthesize complex claims and financial data into plain-language insights and present actionable recommendations directly to executive leaders.

Desired skills and experience:

(Degrees or certifications are optional; equivalent practical experience and demonstrated capability are fully recognized in lieu of credentials).

• •Value-Based Care Execution: Direct 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) are considered a bonus, but are not required where robust, relevant job experience is demonstrated.

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Salary Range: $175,000-$250,000 / year

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package. The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes:

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