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Point32Health Director, Medical Cost Optimization (“LOB”) in Canton, Massachusetts

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here ( .

Job Summary

The Director, MLR Optimization - Medicare / Duals & Exchange (Dir, MLR Opt - Medicare / D&E) is a senior-level position responsible for leading the performance management of Medicare and Duals & Exchange LOBs. The Dir, MLR Opt – Medicare / D&E will lead focused on Medical Loss Ratio (MLR) optimization, connecting key performance indicators (KPIs) to financial targets, and partnering with Market Presidents and Senior Vice Presidents in conjunction with Care Management and Network management team to effectively impact Gross margin and MLR, support business growth, and the realization of Point32Health’s five-year strategy. The Dir, MLR Opt – Medicare / D&E will interact with, SVPs and VPs across Point32Health and collaborate closely with Actuarial, FP&A, Health Care Services, Chief Medical Officer (CMO), Provider Partnership and Operations.

Key Responsibilities/Duties – what you will be doing

  • Accountable to LOB Presidents to optimize financial, operational, and strategic control of the business and P&L to enhance MLR performance.

  • Assess and understand drivers of variance to plans (identified by Actuary through Trend performance reporting) at Member, Provider level and coordinate appropriate action plans to mitigate risks.

  • Lead a team and establish regular cadence for defined Medical Cost Management Forums, focused on MLR optimization, explanation of variances (KPI’s and Medical Cost Trend), with the ability to double click to member, provider, procedure level and generate actionable insights for Accountable Areas

  • Run point on cross-functional activities related to identification of actions that impact MLR (e.g. reporting needs of Care Management to perform specific audits or identification of the right population to manage)

  • Lead the management process of linking Markets KPIs to financial targets and work with Health Care Services (HCS) and other partner areas to implement

  • First level of intake and resolution of MLR related ad-hoc questions from LOB, working closely with Actuarial, HCS and Provider Performance

  • In conjunction with Data & Analytics and Actuary establish frameworks and forums to assess ongoing MLR performance levers, reporting and dashboards.

Qualifications – what you need to perform the job

Education, Certification and Licensure

  • Bachelor’s degree in accounting, finance, mathematics, statistics, business, health care or related field or Statistical or Actuarial qualifications.

  • Master’s/MBA degree strongly preferred

Experience (minimum years required) :

  • 10 years of progressive experience in healthcare analytics, preferably government related business

  • 5+ years of medical economics, actuarial informatics, analytics or highly impactful reporting development experience for a health provider, plan or managed care organization required

  • Strong working knowledge of health insurance claims and health care delivery models required

  • Knowledge of Massachusetts Medicaid and CMS Medicare regulations and related reporting requirements such as STARS, HEDIS, RAF.

  • Experience working in healthcare provider analytics related to revenue modeling, managed care contracting, population management, clinical and financial management.

Skill Requirements

  • Demonstrated ability to exercise critical thinking and logical reasoning and understand the conceptual framework and database relationships underlying health care data required

  • Outstanding oral, written, presentation skills characterized by the ability to communicate effectively with C-suite and executive level audiences required

  • Ability to synthesize and organize large data for meaningful use and action

  • Technical proficiency required in understanding large data structures, Excel, PowerPoint as well as knowledge of majority of the following: Hyperion SmartView, SQL, SAS, Alteryx, Tableau or MicroStrategy

  • Demonstrated ability to master new content quickly

  • Must be able to manage and direct multiple priorities and meet deadlines in a fast-paced environment

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel) :

  • Must be able to work under normal office conditions and work from home as required.

  • Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.

  • May be required to work additional hours beyond standard work schedule.

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

At Point32Health, we strive to be a different kind of nonprofit health and well-being company, with a broad range of health plans, and innovative tools that make navigating health and well-being easier, guiding our members at every step of their health care journey to better health outcomes. We are committed to providing high-quality and affordable health care, improving the health and wellness of our members, and creating healthier communities across the country. The Point32Health name is inspired by the 32 points on a compass. It speaks to the critical role we play in guiding and empowering the people we serve to achieve healthier lives. Our employees are hard-working, innovative, and collaborative. They look for opportunities to grow and make a difference, and they help make us strive to be one of the Top Places to work in New England.