Senior Medical Cost Analytics Advisor

Accountabilities:: Drive medical cost analytics: Identify trends, emerging risks, and cost-saving opportunities across payment integrity and cost containment programs to support broader healthcare affordability objectives. Translate data into strategic insights: Interpret complex analytical findings and communicate clear, actionable recommendations to technical teams, operational stakeholders, and senior executives. Develop financial assessments: Own financial impact analyses and business cases for strategic initiatives, including forecasting, variance analysis, financial modeling, and recommendations to improve program performance. Monitor program effectiveness: Evaluate pre-payment and post-payment editing programs, clinical coding audits, and recovery initiatives through dashboards, performance scorecards, and executive reporting materials. Identify cost recovery opportunities: Analyze billing patterns, coding practices, reimbursement methodologies, and claims data to identify and quantify potential savings, inappropriate payments, waste, and abusive practices. Collaborate across departments: Partner with Finance, Contracting, Coverage Policy, Commercial Payment Integrity, Compliance, Network Analytics, Claims, Reserving, Product, and other enterprise teams to align analytical insights with business decisions. Support vendor management: Conduct data-driven vendor evaluations and sourcing analyses, providing insights to support negotiations, pricing models, contractual arrangements, and performance guarantees. Improve reporting capabilities: Strengthen reporting processes, improve data quality, implement appropriate controls, and develop scalable analytical solutions that support informed decision-making. Modernize analytics processes: Promote automation and the effective use of AI-enabled tools and advanced analytical methods to improve efficiency, accuracy, and analytical capabilities. Support strategic planning: Use analytical findings and program performance insights to inform enterprise priorities, identify improvement opportunities, and contribute to long-term affordability strategies. Ensure compliance and accuracy: Work within regulated healthcare environments, maintaining appropriate analytical controls and supporting audit, claims, and reimbursement-related requirements. Drive continuous improvement: Identify opportunities to enhance analytical methodologies, streamline workflows, and improve the overall effectiveness of payment integrity programs. Requirements: Bachelor's degree in a quantitative or related discipline, such as Economics, Finance, Data Science, Data Analytics, Actuarial Science, Business, Public Health, or Applied Mathematics, or equivalent relevant professional experience. 8+ years of progressive professional experience in medical cost analytics, payment integrity, financial modeling, healthcare analytics, or a related field. Strong analytical and quantitative capabilities, with demonstrated experience evaluating complex healthcare cost data and developing financial impact assessments. Hands-on proficiency with analytical and reporting tools such as SQL, Microsoft Excel, SAS, Tableau, Databricks, or comparable platforms. Strong knowledge of healthcare reimbursement methodologies and medical coding systems, including MS-DRG, APCs, HCPCS, and RBRVS. Familiarity with professional and facility claim structures, billing practices, reimbursement processes, and healthcare payment models. Experience working in regulated and compliance-focused environments, particularly within claims operations, payment integrity, clinical audits, healthcare policy, or related functions. Demonstrated ability to translate complex analytical results into practical business recommendations and communicate findings confidently to senior leadership and executive audiences. Experience developing financial models, forecasts, business cases, variance analyses, and performance measurement frameworks. Understanding of pre-payment and post-payment review processes, coding audits, claims validation, and payment recovery programs. Experience modernizing analytics through automation and advanced analytical methods, including predictive modeling, natural language processing (NLP), and machine learning. Ability to identify practical applications for AI-enabled tools and advanced analytics that deliver measurable business value. Strong stakeholder management and collaboration skills, with the ability to influence decisions and build productive relationships across multidisciplinary teams. Excellent problem-solving, critical-thinking, and organizational skills, with the ability to balance multiple priorities in a complex, matrixed environment. Self-motivated and proactive professional with a strong sense of ownership, accountability, continuous improvement, and commitment to delivering measurable results. Excellent written and verbal communication skills, with the ability to present technical information clearly to both technical and non-technical audiences. Remote work requirement: Candidates working from home must have a cable broadband or fiber-optic internet connection with minimum speeds of 10 Mbps download and 5 Mbps upload. Benefits: Competitive annual salary: $112,800–$188,000, depending on relevant experience, qualifications, and geographic location. Annual performance bonus: Eligibility to participate in an annual bonus program. Comprehensive healthcare coverage: Medical, dental, and vision insurance available from the first day of employment. Wellbeing support: Access to physical, emotional, and behavioral health programs and resources. Retirement savings: Access to a 401(k) retirement plan. Life insurance: Company-paid life insurance coverage. Paid time off: At least 18 days of paid time off annually. Paid holidays: Additional paid holidays throughout the year. Leave benefits: Access to applicable leaves of absence to support personal and family needs. Professional development: Tuition reimbursement to support continued education, skills development, and career advancement. Remote flexibility: Full-time remote working opportunity within the United States. Meaningful impact: Opportunity to contribute to healthcare affordability initiatives, improve payment accuracy, and support more efficient healthcare systems. Career development: Exposure to enterprise-level analytics, advanced technologies, and strategic healthcare initiatives in a collaborative professional environment.