Lead Actuarial Consultant - Risk Adjustment

The Lead Actuarial Consultant, Risk Adjustment Actuarial Services will lead and own actuarial workflows in support of all related risk adjustment activities - primarily risk score model building, scoring claims data, and forecasting expected risk scores. 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. Build, maintain, and own the CMS HCC risk scoring model with appropriate data filtering logic. The model will be reliant on FFS claims data provided by CMS for our ACOs participating in ACO REACH and MSSP (not MAO4s / MMRs). An Analytic/IT team would be at your disposal for data and tool build-up.

2. Lead quarterly risk adjustment analysis and forecasting for the Medicare Advantage and Medicare ACO populations. The individual commercial risk adjustment forecasting may become in-scope in the future.

3. Document and present summary review memos in support of the quarterly risk adjustment analysis and forecasting process in preparation for, and as follow up to, collaboration with various NeueHealth, owned clinics and leaders

4. Lead the evaluation of risk adjustment related financial implications of provider participation in networks for ACO REACH / MSSP opportunities

5. Lead provider risk contract evaluations and ACO REACH / MSSP performance evaluations, interfacing with internal Bright team and external consulting actuaries.

6. Collaborate with Operation Risk Adjustment team in the development of forecasting models, projections and relevant information to inform C-Level business decisions - related to Operational coding improvement activities.

7. Perform ad-hoc data analysis using Excel, SAS, SQL (Databricks)

8. Other duties and responsibilities as assigned.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor's degree required in Math, Statistics, Economics, Actuarial Science, or a related field
• 8+ 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 a CMMI ACO Model (of any kind) is strongly preferred
• 2+ years working with individual/small group ACA rate filings or Medicare Advantage bids is preferred
• Working knowledge of the CMMI Direct Contracting or Accountable Care Organization (ACO) program(s)
• 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 required.