Purpose

Brings a depth of actuarial health plan and leadership experience to Health New England in order to provide oversight, strategic leadership, process improvement and analytical best practices for all members of the Actuarial, Underwriting and Medical Economics / Healthcare Analytics team. Leads an organization that can help drive innovative strategies and provide exceptional business decision support to senior management in support of all lines of business including Commercial Large Group, ACA Small Group & Individual / Merged Market, ASO, Medicare Supplement, Medicaid, and Medicare Advantage.

The Chief Actuary's responsibilities include pricing and rate negotiations, rating tool development and maintenance, provider and vendor risk contracting, cost of care analytics, and claim reserving; as well as more complex and specialized tasks and analysis involving the need for forward-thinking, strategic analysis in collaboration with many other areas of the company. They are responsible for developing solutions that balance costs and risks, conducting regular rate, RX and administration analysis, researching and pricing products, and determining the financial impacts related to product development. They are responsible for developing the organization's Health Plan premium rate structures, through regular and systematic analysis, and forecasting of financial/statistical data in a manner that is actuarially sound, competitive, and that provides margin in accordance with organizational goals and objectives. This position oversees all rate filing processes, which includes both internal analysis and external coordination and collaboration with consultants and regulatory officials, including the Department of Insurance. This position leads the development of risk-sharing budgets and all applicable trends.

This role leads and oversees Health New England's (HNE's) Center for Healthcare Analytics and Business Intelligence, ensuring access to critical data and operational insights. They are responsible for the development and distribution of timely and accurate key performance indicator and utilization / cost trend repots to leadership in support of evaluating the effectiveness of HNE's business strategies, plans and initiatives. The team executes all required compliance reports and ensures they are delivered as outlined in governing regulations, internal policies and procedures. They support product leaders in evaluating overall product performance and supply critical extracts and analytics that enhance decision making.

Key customers include ELT, Sales, Network, Medical Management, and Underwriting leaders. In addition, this position will work closely with the legal department to identify, size, and communicate financial risks and opportunities related to legislative and regulatory changes, including impacts to premiums, benefits, and product designs. The candidate is required to be comfortable both within and outside of the traditional actuarial discipline to broaden his or her sphere of influence. It is crucial to be able to prioritize work for maximum impact while keeping all constituents motivated and engaged.

This position is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England's entity level policies and procedures. The position is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England's Code of Conduct.

Accountabilities

Actuarial and Underwriting:

• Leads the development of trends and other components of rate filings across all applicable product lines. Work collaboratively with key internal stakeholders and external consultants. Lead the follow-up analysis, and research/answer all inquiries from the DOI and other regulatory agencies as necessary.
• Oversee and be responsible for all actuarial aspects of ACA filings and MA bid development, including bid/filing strategy, benefit strategy and design, compliance and management of external and internal actuarial resources and relationships involved with those functions. Provides financial and analytic support, maintenance of rating models, trend development, benefit change valuation and form creation in collaboration with external actuaries.
• Provides Medicaid analytical support. Specifically evaluates the adequacy of Medicaid rates, examines methodologies, analyzes historical data and projects future claims expense to assist in advocacy with the Executive Office of Health and Human Services (EOHHS).
• Evaluates cost of care programs and other strategies designed to control medical costs and resultant trend, enhance product/geographic performance, and generate expansion opportunities.
• Leads efforts with Sales, Underwriting and Analytics to develop, implement and manage an annual Large Group process that ensures the total book of business achieves premium rate targets outlined in the budget.
• Lead group underwriting functions, including self-funded group renewals and proposals.
• Responsibility for decision making, sign-off and strategy regarding actuarial inputs to the monthly financial reporting process and reports, such as claim reserves using paid claims, pended inventory, extensive claim reports, regression and other data tools or methodologies as appropriate. Evaluate all other actuarial reserves for appropriateness.
• Collaborates with Underwriting and Rating, Sales and Product Development to develop and implement appropriate rating strategies for small group, large group, and individual lines of business. Ensures that all strategies are in compliance with rate filings and applicable regulations.
• Builds an understanding of HNE's competitors and the market in general.

Healthcare Analytics and Business Intelligence:

• Leads HNE's Center for Healthcare Analytics and Business Intelligence, which provides effective and consistent analytics and reporting across the organization to promote the intelligence needed for decision-making.
• Provides leadership and direction to the staff of HNE's Center for Healthcare Analytics and Business Intelligence, which includes both an analytics and business intelligence operations team; establishes annual performance objectives and evaluates performance; determines personnel actions.
• Directs the development of health plan analytics, which includes medical and pharmacy cost and utilization analytics, trend and forecasting analyses, and risk adjustment opportunities.
• Identifies medical cost and utilization trends, key drivers, reviewing provider and population variances, and analyzes and communicates factors driving performance.
• Develops performance analytics of medical, pharmacy, care management, population health, and quality initiatives that will reduce overall medical cost while ensuring high quality care and customer satisfaction.
• Responsible for supporting the organizational data governance effort in collaboration with IT executive oversight and members of IT Data Management to ensure the highest data quality, usage of a unified data catalog, appropriate data access (both internal and external), and other functional areas of data governance.

Systems Implementation and Reporting:

• Responsible for state and federal required regulatory reporting (e.g., MA Medicare Supplement Filing, Federal MLR), and provides actuarial support for the development and monitoring of alternate provider reimbursement models.
• Oversee and assure timely and accurate filing of all actuarial deliverables to internal customers, state and federal regulators, internal and external auditors, and other audiences as required for Health New England compliance.
• Ensures that complexity is reduced to produce high-quality work with an eye towards accuracy.
• Manages activities associated with CHIA, DOI, CMS and other external regulatory agencies.
• Leads the development and implementation of new systems and / or procedures that empower data-driven decision making and streamline our workflows.

Compliance and Risk Management:

• Scans and monitors the legislative environment and collaborate with legal department to identify, size, and communicate emerging financial risks and opportunities related to regulatory changes, including impacts on premiums, benefits, and product designs.
• Responsible for leading effective implementation and maintenance of key financial reporting risk management controls.
• Represent Health New England in written and verbal communications, presentations and meetings with regulators and other outside parties regarding matters requiring actuarial expertise, including Committees and the Board of Directors.
• Coordinates and collaborates with HNE leadership to ensure the CFO and ELT have transparent and strong line of sight to organization financial performance, risks, and opportunities.

Strategic Partnership and Leadership:

• Serve as a trusted advisor to all of leadership, providing strategic counsel and financial expertise to support the achievement of our business objectives.
• Collaborate cross-functionally with departmental leaders to align financial strategies with operational priorities, fostering a culture of collaboration and accountability across the organization.
• Leads and drives a customer focused culture throughout their team to deepen client relationships and leverage broader business relationships, systems and knowledge.
• Understands how Health New England's business and culture should be considered in day-to-day activities and decisions.
• Creates an environment in which his/her team pursues effective and efficient operations of his/her respective areas in accordance with Health New England's Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
• Builds a high performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vison/values/business strategy; and, managing succession and development planning for the team.

Minimum Requirements:

Bachelor's degree in Business, Finance, or related field (Master's degree preferred) with a minimum of 10 years of experience performing advanced health care analysis, or an equivalent combination of education and experience. Solid foundation of operational, clinical, and financial healthcare knowledge; an understanding of critical coding / modifier rules and guidelines. Multi-year experience in working with analytics teams to examine and specify unique solutions. Ability to work across complex business and technical teams to understand and specify technology solutions linking analytics business needs to operations. Society of Actuaries (FSA) required. MBA preferred.

• Must have strong financial acumen coupled with an understanding of the success drivers of a provider-owned health insurance plan
• Previous experience with health care insurance, reserve setting, rate development required
• Experience with descriptive, predictive, and prescriptive analytics
• Experience with business intelligence frameworks and solutions
• Experience in data analysis, interpretation, and application
• Demonstrated experience advancing programs by informing and shaping data driven strategy
• Expertise in Excel, Word, PowerPoint, Access and some combination of SQL, SAS and Power BI
• Experience and understanding of modeling languages (SAS, R, Python) and statistical model development
• Able to communicate with business clients in a language they can understand. Effective at translating complex or technical issues into layman's terms. Is articulate and able to communicate in a compelling manner with customers, peers, and staff alike
• Outstanding ability to collaborate and partner with customers, other business teams, and senior leadership
• Ability to work in a dynamic environment with multiple concurrent projects using creativity, flexibility, and organizational skills
• Ability to lead through ambiguity and complexity to take calculated risks to solve problems, forge new paths for growth, and achieve challenging goals
• Confirmed strategic business leadership with experience identifying, quantifying, and pursuing new opportunities
• Exceptional internal/external presentation and verbal communication skills
• Ability to develop direct report(s)
• Demonstrated leadership experience
• Demonstrated ability to work in a Matrix management environment