Community Health Options
Director Actuarial Services & Risk Adjustment
The Director Actuarial Services & Risk Adjustment will be responsible for overseeing the ACA risk adjustment program, the individual and small group pricing functions, reserve valuation and reinsurance programs. The Director Actuarial Services & Risk Adjustment is a leadership role that is responsible for the implementation of a variety of actuarial/statistical practices and analyses around such areas as risk adjustment, reserving, pricing, and planning/forecasting.
Risk Adjustment: The Director of Actuarial Services & Risk Adjustment is responsible for planning, developing, implementing, monitoring, and executing compliant risk adjustment strategies, programs, and initiatives for all aspects of the risk adjustment program for the commercial market. The work of the Director of Actuarial Services & Risk Adjustment will be conducted in accordance with CMS regulations and guidance and Health Options’ Policies and Procedures.
Individual & Small Group Pricing: The Director of Actuarial & Risk Adjustment works in conjunction with the external actuaries and internal partners on pricing and filings for individual and group products and is able to apply actuarial concepts to develop claim costs and to recommend premium rates.
Reserve Valuation & Reinsurance: The Director of Actuarial & Risk Adjustment oversees financial analyst staff with regard to completing the monthly reserve valuation process as well as various claim, risk adjustment, and reinsurance analyses. The Director of Actuarial Services & Risk Adjustment oversees the federal, state, and commercial reinsurance programs.
- Maintains knowledge of regulations and requirements supporting ACA/Commercial Risk Adjustment programs, including Risk Adjustment Data Validation Audits (RADVs)
- Ensures applicable functional areas are informed of new requirements impacts to incorporate changes necessitated by ACA reimbursement policy and regulatory changes
- Ensures Health Options’ Policies and Procedures related to Risk Adjustment are in compliance with official regulations and
- Collaborates with senior management to develop strategies and tactics to improve the accuracy of risk scoring
- Leads the Risk Adjustment team to ensure programs and initiatives are effective, efficient, and contribute to Risk Adjustment score outcomes
- Prepares analyses of Risk Adjustment performance to determine the impact on Health Options’ financial position and premium pricing
- Develops, monitors, and communicates operational and financial performance metrics against prescribed goals
- Provides oversight and accountability for all formal risk adjustment submissions to CMS or applicable regulatory bodies; ensures the accuracy and completeness of data submissions; engages with internal and external partners to resolve any data quality issues
- Develops and implements action plans related to prospective, retrospective, and regulatory data submissions, including detailed work plans, issue logs, and progress reports.
- Manages external partner relationships supporting risk adjustment efforts including contract negotiation, assigning deliverables, establishing goals, monitoring performance, and analyzing program return on investment
- Mentors Health Options’ People on the purpose, guidelines, and initiatives of the Risk Adjustment programs, as necessary
- Collaborates with Provider Networking Team on analytics to support delivering provider education, guidance and training related to complete and accurate diagnostic documentation and coding.
- Oversees the rate filing processes, timelines, and requirements; collaborates with internal partners to ensure deliverables used in rate development are accurate, defensible, and provided in a timely manner
- Tracks Federal and State legislation and regulations related to Fully Insured product lines; legislation and regulations may be of the benefit or rate nature
- Collaborates with Compliance and Product Development to ensure product and rate compliance and oversight
- Proficient in Federal and State rate filing systems
- Directs preparation of analyses in support of reporting Health Options’ financial performance; analyses include, but are not limited to, monthly reserving, statement filings, Bureau of Insurance reports, and financial projections
- Directs and evaluates the work of data analyst(s) in support of monitoring Health Options’ financial performance - analyzes emerging experience, monitors marketplace trends, and identifies issues and risks impacting the business as well as analyzes competitors’ rate filings to gain market intelligence and develops strategies to improve Health Options’ market position
- Understands rate development mechanisms and tests pricing assumptions and the appropriateness of premiums
- Manages the relationship with Health Options’ external actuaries; engages services of the external actuaries, as appropriate
- Recommends updated reserving, pricing, and/or forecasting assumptions, as applicable
- Works with the team to enhance tools and processes used to support the risk adjustment program, valuation, pricing, reinsurance opportunities, and financial reporting
- Develop reports and analyses for reinsurance partners and regulators
People within Community Health Options are expected to work with integrity, humility, strategic vision, curiosity, and discipline. They must be self-motivated, highly effective and compassionate communicators, effectively working with people, work processes, and actively engaging in continuous process improvement.
Health Option diversity initiatives are applicable—but not limited—to our practices and policies on recruitment and selection; compensation and benefits; professional development, and training; promotions; transfers; social and recreational programs, and the ongoing development of a work environment built upon the premise of diversity equity, which encourages and enforces:
- Respectful communication and cooperation between all employees.
- Teamwork and employee participation, permitting the representation of all groups and employee perspectives.
- Work/life balance through flexible work schedules to accommodate employees’ varying needs.
- Employer and employee contributions to the communities we serve to promote a greater understanding and respect for the diversity.
- Bachelor’s degree in Finance, Economics, Math, Business Analytics, Healthcare Administration, or related field
- 5 years of progressive responsibility in healthcare
- Minimum of 5 years of related Risk Adjustment experience within healthcare, including 2 years of leadership experience; or any combination of education and experience, which would provide an equivalent background
- Extensive knowledge of Risk Adjustment payment methodologies and ACA/Commercial Risk Adjustment program regulations and guidelines
- Experience with physician/provider training to improve clinical coding quality preferred
- Experience with legislative and/or regulatory pricing processes
- Technical skills to build models, predict outcomes and assess future impacts
- Detail oriented; possesses strong initiative and ability to set priorities
- Demonstrated ability to champion change and foster a culture of continuous improvement
- Strategic and entrepreneurial outlook with strong collaboration skills
- Strong relationship building skills that synergize with peers, senior management, and external partners
- Strong analytic and quantitative problem-solving skills; proficient with data manipulation tools (SQL, Access)
- Demonstrated track record for achieving performance results
- Excellent written and verbal communication skills, as well as presentation skills; ability to explain complex topics in an easy to understand manner and to interact with senior leadership with confidence and authority
- Proficient with Microsoft Office products (Word, Outlook, Excel, PowerPoint)
- Strong ability to maintain production levels and quality goals with minimal direct supervision
- Able to manage multiple priorities and deadlines in an expedient and decisive manner
REPORTS TO: Chief Financial Officer
This is a remote position that includes a Total Rewards Program that is designed to enhance the lives of our people (i.e., cultivate a commitment to health, pay for current healthcare and dependent care costs, and provide a tax-effective vehicle to accumulate funds for retirement).
- Health, Dental and Vision Insurance
- Employer paid Group Life, STD and LTD Insurance
- Wellness Program
- 401(k) Retirement Plan with Employer match
- Workplace Flexibility and Workplace Transition Program
- Dependent Care Flex Spending
- Vacation time, Holidays, Floating Holidays, Personal Health time, Maine Earned Paid Leave, Parental Paid Leave
- Professional Development/Education Reimbursement