Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015. This position provides a wide range of actuarial expertise and support to the company, including responsibility for the actuarial portion of all Medicare product bids to CMS, USFHP rate negotiations with the Department of Health Administration (DHA) representation with external actuaries and others, planning and performance monitoring, expertise, consultation, analysis and reporting surrounding medical expense. As a largely individual contributor, this position must function well in a matrix management environment.
- In conjunction with Generations Advantage (GA) leadership and EMT, analyze, develop, and submit Medicare Advantage and Prescription Drug (MA/PD) plan Bid Pricing Tools (BPTs) in compliance with CMS regulations and timelines to meet corporate objectives for growth and profit margin.
- Collaborate with GA leadership on estimates for Risk Revenue. Monitor changes and updates to the risk adjustment approach employed by CMS.
- Prepare and analyze monthly estimates for Medicare Part D Risk Corridor and Coverage Gap Discounts. Perform annual reconciliation and prepare required certifications.
- Oversee preparation of the financial portion of all Medicare product quotes, including, among others, employer EGWP (MA/MAPD), SNPs, and other such products.
- Oversee and support all Finance related Part C and Part D reporting requirements for Medicare.
- Has lead responsibility for preparation and presentation of annual Healthplan LOB’s revenue and healthcare expense budget.
- Designs and implements measurement and monitoring of key performance metrics to identify trends and variances from budget and enable corrective actions on a timely basis.
- Provide analysis and advice to support the USFHP annual rate negotiation.
- Develop reporting and lead analysis of medical expense, consulting with medical management leadership, product leadership, CFO and finance team.
- Lead analysis and calculation of incurred but not reported claims (IBNR).
- Develop and maintain knowledge and expertise in regional and national managed health care trends and best practices, seeking opportunities to translate those to Martin’s Point.
- Manage the process for annual medical cost and utilization projections and forecasts, by coordinating resources, expertise and information in concert with the financial planning cycle.
- Provide oversight to all key financial arrangements that pertain to GA and USFHP, including payment programs to internal and external providers and all risk arrangements with providers.
- Assess monthly variances between projected and actual expenses in reports on medical expense.
- Provide expertise and consultation on a wide-array of business functions including, but not limited to provider reimbursement, claims processing, benefit adjudication, and compliance
- Collaborate with leadership and staff from Finance, Martin’s Point Health Centers, Health Management, Network Management, Informatics, Health Plan Service Center, Quality Management, Program Integrity, Corporate Planning, etc.
- Support senior management (Chiefs and VPs) with special projects and research, including compiling white papers on special topics, as needed.
- Bachelor’s degree in actuarial science, math, statistics or a related field is required.
- 8-10 years of progressive actuarial experience in a wide range of medical expense analyses, contracting in a managed care setting, preferably in commercial and government programs business.
- Experience developing and managing a wide array of financial arrangements is preferred.
- The following licensure(s), certification(s), registration(s), etc., are required for this position, which must be maintained in good standing:
- Minimum Required: Associate of the Society of Actuaries and Member of the American Academy of Actuaries.
- Preferred: Fellow of the Society of Actuaries
Exclusion from Federal Programs
Employee may not at any time have been or be excluded from participation in any federally funded program, including Medicare and Medicaid. This is a condition of employment. Employee must immediately notify his/her manager or the Clinic’s Compliance Officer if he/she is threatened with exclusion or becomes excluded from any federally funded program.
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martin’s Point Health Care? Contact us at: email@example.com