Payer Analytics Consultant (Defined Term)

Summary

Central California Alliance for Health is a regional nonprofit health plan serving communities through accessible, quality healthcare and local innovation. The Payer Analytics Consultant will design and validate managed care payer models, analyze reimbursement methodologies and financial outcomes, and collaborate with stakeholders to advance payer reimbursement objectives.

Responsibilities

• Designs and validates managed care payer models and performs moderately complex analysis to evaluate the feasibility of payer reimbursement methodologies
• Conducts moderately complex financial analysis to support successful payer reimbursement outcomes
• Coordinates and collaborates with internal and external stakeholders to achieve payer reimbursement objectives

Skills

• Technically strong, with proven experience in payer financial modeling, provider payment methodologies, payment structure design, and reimbursement strategy development
• Analytical and detail-oriented, skilled in data interpretation, trend analysis, and scenario modeling to inform decision-making and optimize payment accuracy
• Collaborative and solutions-focused, working effectively across departments — including finance, provider network management, operations, and clinical teams — to align analytics with business goals
• A clear and professional communicator, able to explain complex financial and analytical concepts to both technical and non-technical audiences
• Relationship-driven, fostering productive partnerships with internal stakeholders and external partners to support shared priorities and ensure alignment
• Curious and improvement-minded, continuously seeking opportunities to enhance data quality, streamline processes, and support innovative payment strategies
• Windows based PC systems and Microsoft Word, Outlook, PowerPoint, Access, Visual Basic, and Excel (including pivot tables), and database systems
• Methods and techniques of financial modeling and analysis
• Principles and practices of provider reimbursement methodologies, pricing, and fee schedules for all provider types, including hospital, physician, and ancillary providers
• Healthcare industry specific terms and healthcare related data types and structures, including member, claims, clinical, and provider types
• National standards for fee-for-service and value-based provider reimbursement methodologies, including risk-sharing models
• Data modeling techniques and business analytical and data mining tools, including SQL, and data visualization tools, such as Tableau
• Collect, interpret, and evaluate data, detect patterns, brainstorm solutions, consider multiple factors when making decisions, and project consequences of recommendations
• Demonstrate strong analytical, critical thinking, and research skills, identify and troubleshoot issues, identify alternative solutions, and make recommendations for action
• Translate data into understandable information and deliver solutions that improve business processes
• Act as a technical resource, provide guidance related to area of assignment, and explain related regulations, processes, and programs
• Interpret and apply rules, regulations, policies, procedures, and guides
• Work collaboratively with individuals at all levels of the organization while supporting multiple stakeholders
• Bachelor's degree in Business Administration, Accounting, Finance, Healthcare, or a related field
• A minimum of three years of experience performing financial healthcare reimbursement analysis (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
• This position can be filled within any of our Alliance service areas, or remotely within the Pacific, Mountain and Central time zones
• Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship
• While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa

Qualifications

Must Haves

• Technically strong, with proven experience in payer financial modeling, provider payment methodologies, payment structure design, and reimbursement strategy development
• Analytical and detail-oriented, skilled in data interpretation, trend analysis, and scenario modeling to inform decision-making and optimize payment accuracy
• Collaborative and solutions-focused, working effectively across departments — including finance, provider network management, operations, and clinical teams — to align analytics with business goals
• A clear and professional communicator, able to explain complex financial and analytical concepts to both technical and non-technical audiences
• Relationship-driven, fostering productive partnerships with internal stakeholders and external partners to support shared priorities and ensure alignment
• Curious and improvement-minded, continuously seeking opportunities to enhance data quality, streamline processes, and support innovative payment strategies
• Windows based PC systems and Microsoft Word, Outlook, PowerPoint, Access, Visual Basic, and Excel (including pivot tables), and database systems
• Methods and techniques of financial modeling and analysis
• Principles and practices of provider reimbursement methodologies, pricing, and fee schedules for all provider types, including hospital, physician, and ancillary providers
• Healthcare industry specific terms and healthcare related data types and structures, including member, claims, clinical, and provider types
• National standards for fee-for-service and value-based provider reimbursement methodologies, including risk-sharing models
• Data modeling techniques and business analytical and data mining tools, including SQL, and data visualization tools, such as Tableau
• Collect, interpret, and evaluate data, detect patterns, brainstorm solutions, consider multiple factors when making decisions, and project consequences of recommendations
• Demonstrate strong analytical, critical thinking, and research skills, identify and troubleshoot issues, identify alternative solutions, and make recommendations for action
• Translate data into understandable information and deliver solutions that improve business processes
• Act as a technical resource, provide guidance related to area of assignment, and explain related regulations, processes, and programs
• Interpret and apply rules, regulations, policies, procedures, and guides
• Work collaboratively with individuals at all levels of the organization while supporting multiple stakeholders
• Bachelor's degree in Business Administration, Accounting, Finance, Healthcare, or a related field
• A minimum of three years of experience performing financial healthcare reimbursement analysis (a Master's degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying
• This position can be filled within any of our Alliance service areas, or remotely within the Pacific, Mountain and Central time zones
• Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship

Nice to Haves

• While we encourage all interested applicants to apply, we do give priority to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa

Benefits

• Medical, Dental and Vision Plans for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• Ample Paid Time Off for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• 12 Paid Holidays per year for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• 401(a) Retirement Plan for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• 457 Deferred Compensation Plan for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• Robust Health and Wellness Program for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• Onsite EV Charging Stations for all regular Alliance employees working more than 30 hours per week; some benefits are available on a pro-rated basis for part-time employees, and these benefits are unavailable to temporary employees while on an assignment with the Alliance.
• Hybrid work environment.
• Some staff may work full telecommuting schedules.