Director, Actuary

Your Role

The Risk Adjustment team is accountable for developing an end-to-end strategy and managing programs to ensure coding completeness and accuracy. The Director, Actuary will report to the Vice President of Risk Adjustment. In this role you will lead the risk adjustment analytics team to inform prospective and retrospective risk adjustment programs for Medicare, ACA, and Medi-Cal. You will work cross functionally with other departments such as quality, provider network, claims, and compliance to align on goals and build efficiencies. You will also drive strategy and resource allocation through foundational analytics and reporting.

Your Work

In this role, you will:

• Support product design and development, provider contracting, care management and pricing strategy solutions, rate filings, benefit filings and/or network filings

• Manage business unit planning and strategies that support the development and execution of Plan, long-term strategies and incentive metrics

• Ensure timely tracking of results and course correction activities as needed

• Responsible for understanding current and emerging regulatory and competitive developments, facilitating communication of these developments, and ensuring processes and procedures are consistent with changing regulations

• Lead all risk adjustment analytics efforts, inclusive of identification of potential conditions, provider reporting, and all analytics associated with prospective and retrospective programs

• Collaborate with shared service partners, including provider network / contracting/ engagement, claims, compliance, and finance/actuarial to improve coding completeness and accuracy

• Oversee the development of new reports to drive risk adjustment strategy

• Create actionable reporting and proactively pursue ad hoc analytics to identify and prioritize areas of opportunity to improve coding completeness and accuracy 
• Ensure effective allocation of resources amongst prospective and retrospective risk adjustment programs drive by accurate data and analytics
• Create actionable provider tools and reporting to support coding completeness and accuracy

Your Knowledge and Experience

 

• Requires a bachelor's degree in actuarial science, mathematics, statistics, computer science or related field and 10 years prior relevant job including 3 years of management experience

• Requires ASA or FSA

• Requires working knowledge of the Medicare, ACA, and Medi-Cal risk adjustment models

• Requires experience with Medicare Advantage and/or ACA plans preferred