Job Overview
- Manage, analyze, and report medical and pharmacy claims to identify cost drivers, utilization trends, and opportunities to optimize benefit design and vendor performance.
- Develop trend analyses and forecasting models to support healthcare cost projections, budgeting, and scenario planning.
- Apply industry knowledge and data analysis to identify inefficiencies, cost drivers, and performance gaps and recommend strategies to improve spend while protecting member outcomes.
- Conduct benchmarking analyses to assess the competitiveness of benefit programs and identify gaps and opportunities for improvement.
- Evaluate and recommend benefit design changes (e.g., medical, dental, vision, disability, life insurance) to support effective plan management, cost efficiency, and a strong employee experience.
- Define key financial, clinical, and utilization metrics to assess health plan performance and establish reporting to monitor those indicators.
- Facilitate internal Chief Medical Officer involvement through regular updates and escalation of material clinical, utilization, or cost trends, as needed.
- Support evaluation of clinical programs, including case management initiatives and related vendor partnerships, to assess impact on health outcomes and cost of care.
- Evaluate plan and vendor performance (financial, clinical, operational, and member experience outcomes, including ROI analysis) to support contract renewals and strategic partnerships.
- Support benefits strategy and leadership through analysis, reporting, and recommendations related to benefit programs and plan design.
- Develop and present clear, compelling materials that communicate key insights and recommendations to senior-level executives.
- Lead projects by aligning stakeholders, communicating progress, and ensuring timely delivery of required work products.
- Identify opportunities to leverage on-site health centers to improve member health outcomes and reduce external claims costs.
- Perform other duties and special projects as assigned by the Sr. Director, Health Plan and Benefits.
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