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Senior Lead Utilization Analyst

Job Ref: 78125
Category: Professional
Department: ANALYTICS AND REPORTING
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Salary Range: $108,450.00 - $118,450.00

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview
Under the Chief Financial Officer and the Head of Health Analytics, the position of Lead Utilization Analyst is responsible for driving the research and reporting of utilization, quality, and financial data to provide timely, meaningful, actionable insights to a multitude of teams within the Medical Management department. This role will focus on utilization, performance, and efficacy of various health services, including MLTC, Behavioral Health, Partnership in Care, Integrated Case Management, and Utilization Management.


The successful candidate must have healthcare experience & be able to work autonomously AND collaboratively with other Health Analytic team members, and with various SMEs and key decision makers across the organization. Technical proficiency and sharp healthcare / health plan industry knowledge are desired equally—the ability to effectively communicate with business users of varying data competencies & complexity in business needs and objectives is very important.


Key responsibilities include the design, development, enhancement, and maintenance systems that support operations within different departments within the larger Medical Management (including Quality, Medicare Stars, Contracting, Finance, Utilization, Integrated Case Management, and other health services like MLTC, HIV/SNP).


Additionally, the Lead Utilization Analyst will utilize data to identify more efficient and effective business processes within Medical Management.


This position requires an analytical-minded individual who enjoys and thrives working in a fast-paced, challenging, but rewarding environment.

Job Description

  • Drive various designated and cross-functional reporting, using Plan data to provide analysis and research related to the utilization, performance, and efficacy reporting of different health care services and lines of businesses under Medical Management.
  •  Responsible for research, collection, analysis and presentation of the Plan’s integrated utilization, quality,
  • and financial data. The individual must work with departments within the Plan to coordinate analytics to enhance operational efficiencies.
  • Create dashboards, report cards, and other meaningful data visualization offerings and presentations communicate actionable & timely findings to a variety of key decision makers.
  •  Communicate and translate raw data and information between different groups. Use data to show end results and impact of actions.
  • Drive the delivery & management of standard weekly, monthly, and quarterly reports, as well as numerous other ad hoc reporting.
  •  Prepare & conduct financial related analyses on various aspects of the Medical Management and Contracting operations of the Plan including utilization, payment, rate structure, and membership.
  •  Prepare & conduct projection analyses on claims and utilization, including underlying trends and risk analysis.
  •  Prepare analyses of medical service from large, shared databases utilizing queries and multiple level extracts.
  •  Contribute to the planning, delivery, and maintenance of the Monthly Indicator Report. Identify key performance indicators that can be tied to plan strategy and highlight specific indicators for deeper analysis and discussion. Make recommendations to retire or revise other indicators that do not warrant close review.
  •  Manage all analytical reporting requests in an assigned queue; keep current with all reporting needs and manage multiple projects at one time.
  •  Works with clinical and non-clinical users to understand reporting needs, and to ensure that reporting is done in a clear and concise manner.
  •  Facilitate process improvement within the department via program & performance evaluation.
  •  Provide subject matter expertise and operational support to Medical Management Department.
  •  Collaborate with other Health Analytics team members and other departments & SME’s to understand company needs and devise possible solutions including data integrity  data governance solutions to remove joint obstacles to timely and high-quality data analytics.
  •  Liaison between business decision makers, contracting, business SMEs, IT, and project resources & workgroups to facilitate results through the project lifecycle phases and ensure business expectations are being met for delivery.

Minimum Qualifications

  •  Bachelor’s degree in Health Sciences, Statistics, Biostatistics, Epidemiology, Health Informatics, HealthEconomics, or similar field (Master’s degree preferred).
  •  Health insurance experience is required.
  •  5-8 years required experience in progressively complex healthcare data analytics / statistical analysis.
  •  3-5 years’ experience interacting with internal clients for report development and execution, especially with reporting actionable activity by / for clinicians.
  •  Fluent in TSQL (required), Tableau or Power BI (desired), and SAS/R (desired).
  •  Proficiency in understanding and analyzing both professional and facility claims (required).
  •  Experience in utilization management, case management, VBP arrangement highly desired.
  • Ability to translate business requirements to analytical deliverables.
  •  Experience in performing clinical program evaluation (desired).
  • Self-motivated is a must.

Professional Competencies 

  • Integrity and Trust
  • Customer Focus
  • Functional/Technical skills
  •  Excellent verbal and written communication skills, including experience preparing and presenting to internal customers at all levels of the organization