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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.
We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
The Senior Consultant, Risk Adjustment Actuarial Services will lead and own actuarial workflows in support of all related risk adjustment activities and support of our ACA payer risk share contracts. This entails primarily risk score model building, scoring claims data, and forecasting expected risk scores or assessment of payer premiums and/or risk transfers. In addition, this role will support coding accuracy improvement workflows in evaluation of impacts to scores and forecasted revenue. Risk scoring with the CMS HCC and HHS HCC models are currently in scope, supporting our beneficiaries within the Medicare Advantage, Medicare ACO, and commercial individual markets. Additional cross-functional support role working with Line of Business, Analytics, Finance, Marketing and other areas of the company that may need data summarization, modeling framework or research help related to risk adjustment.
ROLE RESPONSIBILITIES
1. Supplement and/or enhance current inhouse CMS and HHS HCC risk scoring model with appropriate data filtering and eligibility logic. The model will be reliant on FFS / encounter claim data provided by CMS (ACOs) or from payers (Medicare Advantage or ACA Individual plans). An Analytic/IT team would be at your disposal for data and tool build-up support.
2. Lead quarterly risk adjustment analysis and forecasting for the Medicare Advantage, Medicare ACO, or ACA populations.
3. Collaborate with Operational Risk Adjustment team in the development of forecasting models, ROI analyses, and projections / relevant information to inform C-Level business decisions – related to Operational coding improvement activities.
4. Lead or Assist with Monthly claim reserving workflows for following lines of business: ACO REACH / Medicare Advantage / ACA Individual
5. Lead or Assist with provider risk contract evaluations and ACO REACH / MSSP performance evaluations, interfacing with internal Bright team and external consulting actuaries.
6. Perform ad-hoc data analysis using Excel, SAS, SQL (Databricks)
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
• Bachelor’s degree required in Math, Statistics, Economics, Actuarial Science, or a related field
• 4 - 12 years of actuarial experience with 5+ years working within healthcare
• 3+ years working with a CMS/HHS HCC risk adjustment modeling is required
• 2+ years working with an individual/small group ACA commercial insurance is strongly preferred
• 1+ years working with ACO (REACH/MSSP) or Medicare Advantage bids is preferred
• Working knowledge of industry value-based contracts between payers and providers (risk sharing arrangements)
• Experience leading projects and ownership of deliverables
PROFESSIONAL COMPETENCIES
• Proficient in Microsoft Excel (VBA, advanced data visualization, etc.) and other Office products
• Experience with forecasting, modeling, SQL (Databricks experience is a plus)
• Experience with SAS based tools (CMS risk adjustment models)
• Understanding of company practices related to management of member populations for purposes of estimating risk
• Produce, understand, and interpret internal and external analysis and reports; provide effective technical and non-technical support to internal and external stakeholders
LICENSURES AND CERTIFICATIONS
• Associate of the Society of Actuaries is strongly preferred.
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
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