Director of Actuarial Services

It's an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Director of Actuarial Services is a key member of the Finance leadership team. Working closely with the CFO, the Chief Actuary, Product and Marketing leadership, and other internal and external stakeholders, the Director will play an integral role on ensuring the financial soundness and profitable growth of Medicare products, by leading the annual CMS bids, developing financial analytics / reporting, and identifying profit and growth opportunities. The position oversees the measurement and reporting of medical expense trends for all lines of business, with a goal of identifying medical expense savings opportunities and recommending performance improvement initiatives, as well as risk adjustment analysis primarily related to the MassHealth Medicaid, New Hampshire Medicaid, and Medicare lines of business, directly impacting and improving the revenue for these products.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

Key Functions/Responsibilities:

Strategic Actuarial Leadership

* Serve as the actuarial lead for financial oversight and strategy on Medicare products.

* Partner with business leadership to evaluate product performance, growth opportunities, and risk mitigation strategies.

* Guide actuarial modeling to support forecasting, profitability analysis, and product development.

* Represent Finance as a subject matter expert in regulatory and strategic discussions.

Medicare Actuarial Oversight

* Lead the development and coordination of CMS bid submissions for Medicare Advantage and Part D products.

* Oversee the actuarial framework for Medicare, including membership trends, revenue and claims forecasts, risk adjustment, and competitive analysis.

* Direct development of Part D accruals, revenue models, and financial tracking tools.

* Stay current on CMS regulations and apply actuarial insight to policy changes and market dynamics.

Risk Adjustment Strategy and Analytics

* Lead enterprise-wide risk adjustment strategy and oversight, including data validation, version control, revenue impact analysis, and ROI modeling.

* Support risk score normalization in forecasting models and evaluate discrepancies between reported and actual risk scores.

* Collaborate with risk coding, IT, and compliance teams to ensure accuracy in CMS and state risk submissions.

* Advocate for risk model adjustments with state agencies by evaluating bias, population impact, and systemic changes.

Medical Expense Trend Analysis

* Lead monthly trend reviews across all lines of business, partnering with product, actuarial, utilization management, and finance teams.

* Analyze PMPM, cost per use, utilization per 1000, unit cost vs. severity, and normalized trends based on acuity or fee schedule shifts.

* Identify cost containment opportunities and recommend targeted performance initiatives.

* Integrate provider profiling and benchmarking against state actuary pricing targets to identify gaps and guide corrective actions.

Regulatory Reporting and Compliance

* Prepare and oversee financial regulatory submissions to federal and state agencies, including bid filings, audits, and quarterly/annual reporting.

* Ensure compliance with actuarial standards and support internal and external audit requests.

* Lead development of defensible actuarial assumptions and documentation.

Cross-Functional Collaboration

* Collaborate with pharmacy analytics to evaluate Part D trends and identify actionable insights.

* Coordinate with provider analytics to track unit cost histories and analyze provider-level trends.

* Participate in Under/Over Utilization Management initiatives to identify high-value care opportunities.

* Drive integration between actuarial, product, finance, and clinical teams to ensure a cohesive financial strategy.

Team Leadership and Development

* Manage, mentor, and develop a team of actuaries and healthcare analysts.

* Provide technical direction, goal setting, and performance management.

* Foster a culture of innovation, accountability, and continuous improvement.

* Attract and retain talent aligned with the organization's mission, culture, and analytic goals.

Supervision Exercised:

• Directs 2 - 5 staff within multiple functions

Supervision Received:

• General supervision is received weekly

Qualifications:

Education Required:

* Bachelor's degree in actuarial science, Economics, Statistics, Mathematics, Finance, Health Care Administration, or related field required

Education Preferred:

• Master's Degree in related field is strongly preferred
• Fellow of the Society of Actuaries (FSA) or Associate of the Society of Actuaries (ASA)

Experience Required:

• Eight (8) + year's progressively responsible experience in health actuarial analytics required, with four (4) + years of prior management experience strongly preferred

Certification or Conditions of Employment:

• Pre-employment background check

Competencies, Skills, and Attributes:

• Expert analyst with an ability to translate findings into real world solutions
• Ability to use well developed interpersonal skills to direct and influence the efforts of others, both internally and externally
• Ability to conceptualize and envision the impact of change, and propose new ways to do business
• Proficiency with SAS/SQL and MS Excel
• Working knowledge of at least one of the following risk adjustment methodologies DxCG, CDPS+Rx, CMS Medicare Advantage HCC Model, ACA HCC Model
• Ability to meet deadlines, multi-task, problem solve and use appropriate technology to analyze business problems. Project management skills a plus
• Strong communications skills, both verbal and written, are required
• Strong understanding of health care data and analytical methodologies
• Strong team player
• Effective collaborative and proven process improvement skills

Working Conditions and Physical Effort:

• Work is performed in a remote working environment
• No or very limited physical effort required
• No or very limited exposure to physical risk

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees