Director Actuarial Services

1 week ago

Lewiston, United States Community Health Options Full time

**Join our team text RISK to 207-367-3977 to apply**

***

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.

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.

**DESCRIPTION**
- 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 a

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