SCOPE OF ROLE

The Director, Actuarial Services – Risk Adjustment (RA) will have the lead role in actuarial studies and modeling of risk scores for Medicare Advantage (Med Adv), Direct Contracting Entity (DCE), Individual and Family Plans (IFP) and Small Group (Sm Grp) Affordable Care Act (ACA) plans as well as supporting analysis and engagement efforts the company employs to improve overall risk score and performance.

ROLE RESPONSIBILITIES

The Director, Actuarial Services – RA job description is intended to point out major responsibilities within the role, but it is not limited to these items:

• Lead the design and evaluation of risk adjustment forecasting methodologies across Med Adv, DCE, and ACA lines of business
• Engage with Risk Adjustment leadership to establish and review quality processes that ensure the timely completion of model runs, data and result validation, and updates due to coefficient and hierarchy changes in the CMS models
• Collaborate with actuarial leadership (including line of business actuaries) to ensure the completion of efficient and accurate forecasts for business deliverables, including Med Adv bids, line of business forecasts, ACA risk transfers, and IBNR
• Guide the ROI analysis of external EDGE vendor, providing insights and recommendations to leadership regarding their programs and processes
• Guide the ROI analysis on internal engagement programs that are being tested before a national rollout is performed, providing insights and recommendations to leadership
• Lead partnership with IT to ensure the quality and availability of data, including data audits and error validation
• Support risk adjustment and med econ processes across the enterprise
• Manage and mentor Consulting Actuaries and Analysts to achieve work deliverables and ensure their development relative to team growth goals
• Provide support for other actuarial teams during their peak periods, including Med Adv desk review and IFP rate objections
  Other duties and responsibilities as assigned

SUPERVISORY RESPONSIBILITIES

• This position will have supervisory responsibilities including Consulting Actuaries and Analysts

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• A Bachelor’s degree in Math, Statistics, Economics, Actuarial Science, or a related field is required
• Eight (8) or more years of experience working as a health care actuary, with a minimum of 3 years with Medicare Advantage and/or ACA RA is required
• Associate or Fellow of the Society of Actuaries
• Meets or exceeds continuing educations requirements for SOA and the American Academy of Actuaries
• Expert understanding of how ACA and Med Adv risk adjustment works, the key drivers and most influential variables; working knowledge of DCE risk adjustment preferred
• Understanding of healthcare claims data

PROFESSIONAL COMPETENCIES

• Proficient in Microsoft Excel and other Office products
• Experience with forecasting, modeling, and SQL or SAS
• Expert level knowledge of risk adjustment for ACA and Med Adv required; DCE products knowledge preferred
• Produce, understand, and interpret internal and external analyses and reports; provide effective technical and non-technical support to internal and external stakeholders
• Strong communication and collaboration skills
• Strong management and leadership skills

LICENSURES AND CERTIFICATIONS

• Associate or Fellow of the Society of Actuaries

WORK ENVIRONMENT

Most work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.