Carolinas MGMA
Payment Model Analyst-Population Health Management
Carolinas MGMA - Wilmington, Delaware, us, 19894
Work at Carolinas MGMA
Overview
- View job
Overview
Primary Functions:
The Analyst, Payment Models is a critical role supporting Nemours' enterprise-wide payment model strategy, with a primary focus on the Global Budget Program. This position is responsible for analyzing, tracking, and reporting on total cost of care (TCOC) and ensuring that financial, claims, and utilization data are effectively integrated to drive payment model performance, cost management, and strategic decision-making.
This role reports to the Manager, Global Budget, operates at the intersection of multiple teams and data ecosystems, serving as a key partner to Population Health Analytics, Managed Care Analytics, Finance & Accounting, consultants, vendors, and external stakeholders. The success of the Global Budget program depends on a seamless flow of financial and actuarial insights, and this position ensures alignment between financial modeling, performance reconciliation, and risk-adjusted cost assessments.
The position plays an integral role in the annual lifecycle of global budget analyses and reporting, supporting:
Baseline financial modeling & revenue projections, ensuring accurate cost assumptions and payer calculations.
Mid-year performance tracking, identifying trends in utilization, claims, and service volumes.
End-of-year reconciliation and reporting, ensuring all adjustments (case mix, policy shifts, and methodology refinements) are captured accurately.
This role requires strong technical proficiency in SQL, Power BI, Oracle ERP, and other cloud-based analytics tools, alongside deep expertise in decision support systems, HIPAA/HITECH compliance, and hospital finance data elements (CPT, DRG, APDRG, risk groupers, ERP).
Essential Functions:
Leverage Expertise:
Supports analysis of actual vs. expected cost trends across Nemours' payment models, identifying drivers of variation and financial risk. Implements structured cost-of-care reporting that informs financial decision-making, payment reform strategy, and risk mitigation efforts. Supports the annual reconciliation of GRB financials, working closely with finance, population health, and external actuarial consultants. Ensures that methodology refinements, exclusions, case mix adjustments, and market shift impacts are properly accounted for in financial performance assessments. Data Integration & Reporting:
Develops and implements SQL-based queries, dashboards, and structured reporting tools to translate raw financial and claims data into actionable insights. Works with IT and enterprise analytics teams to optimize data extraction from EPSi, Crystal Reports, Clarity Extracts, Epic, and EMR sources. Supports data visualization development in Power BI, Qlik, and Tableau, ensuring stakeholders have real-time access to cost and payment model performance. Data and Decision Support:
Assesses utilization patterns and service mix trends that influence cost-of-care performance, aligning financial data with clinical insights. Engages with Managed Care Analytics and Population Health to ensure financial insights are integrated with quality, access, and efficiency initiatives. Ensures alignment between financial analytics and clinical payment methodologies, integrating CPT, DRG, APDRG, risk groupers, and ERP-based cost structures. Supports structured costing methodologies to ensure accuracy in financial projections and TCOC benchmarking. Develops and refines GRB financial performance reports to provide leadership with clear, actionable insights. Regulatory & Compliance Integration:
Ensures that all data analytics and financial reporting comply with HIPAA, HITECH, PHI, PII, and CSI security standards. Collaborates with compliance teams to mitigate data privacy risks while optimizing analytic capabilities. Enterprise Reporting & Performance Optimization: Collaboration:
Supports Nemours' evolving value-based care strategy, ensuring analytic frameworks align with enterprise-wide payment transformation initiatives. Works proactively in a matrixed environment, collaborating across finance, analytics, actuarial, and population health teams. Engages with external consulting partners (Milliman, Medicaid regulators, payer stakeholders) to align financial reporting with evolving payment model requirements. Other duties as assigned. Job Requirements: Bachelor's degree. Advanced Degree Preferred in healthcare management, health policy, medical economics, hospital finance, or related fields 3-5 year of relevant work experience.
#J-18808-Ljbffr
Supports analysis of actual vs. expected cost trends across Nemours' payment models, identifying drivers of variation and financial risk. Implements structured cost-of-care reporting that informs financial decision-making, payment reform strategy, and risk mitigation efforts. Supports the annual reconciliation of GRB financials, working closely with finance, population health, and external actuarial consultants. Ensures that methodology refinements, exclusions, case mix adjustments, and market shift impacts are properly accounted for in financial performance assessments. Data Integration & Reporting:
Develops and implements SQL-based queries, dashboards, and structured reporting tools to translate raw financial and claims data into actionable insights. Works with IT and enterprise analytics teams to optimize data extraction from EPSi, Crystal Reports, Clarity Extracts, Epic, and EMR sources. Supports data visualization development in Power BI, Qlik, and Tableau, ensuring stakeholders have real-time access to cost and payment model performance. Data and Decision Support:
Assesses utilization patterns and service mix trends that influence cost-of-care performance, aligning financial data with clinical insights. Engages with Managed Care Analytics and Population Health to ensure financial insights are integrated with quality, access, and efficiency initiatives. Ensures alignment between financial analytics and clinical payment methodologies, integrating CPT, DRG, APDRG, risk groupers, and ERP-based cost structures. Supports structured costing methodologies to ensure accuracy in financial projections and TCOC benchmarking. Develops and refines GRB financial performance reports to provide leadership with clear, actionable insights. Regulatory & Compliance Integration:
Ensures that all data analytics and financial reporting comply with HIPAA, HITECH, PHI, PII, and CSI security standards. Collaborates with compliance teams to mitigate data privacy risks while optimizing analytic capabilities. Enterprise Reporting & Performance Optimization: Collaboration:
Supports Nemours' evolving value-based care strategy, ensuring analytic frameworks align with enterprise-wide payment transformation initiatives. Works proactively in a matrixed environment, collaborating across finance, analytics, actuarial, and population health teams. Engages with external consulting partners (Milliman, Medicaid regulators, payer stakeholders) to align financial reporting with evolving payment model requirements. Other duties as assigned. Job Requirements: Bachelor's degree. Advanced Degree Preferred in healthcare management, health policy, medical economics, hospital finance, or related fields 3-5 year of relevant work experience.
#J-18808-Ljbffr