The posting
Your Future is our Future
At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.
We're excited to consider every qualified candidate authorized to work in the United States, although we are unable to sponsor visas for this role at this time.
Position:
VP, Medicare Advantage Chief Actuary
Position Summary:
Provides oversight, strategic direction, process improvements, and best practices for the department. Responsible for all actuarial and underwriting/pricing functions in support of Essence Healthcare’s Medicare Advantage plan operations. Partnering closely with the leaders of Risk Adjustment, Pharmacy, Health Plan Product, and Stars Strategy, this role delivers forward-thinking strategies and provides business direction regarding actuarial rate setting, pricing, annual CMS Part C and Part D bid submissions, risk adjustment factor forecasting, premium development, valuation and statutory reserve setting (including IBNR), financial risk management, product development, and performance analytics to maintain long-term financial sustainability, market competitiveness, and high Star Ratings performance.
Job Description:
Primary Responsibilities:
- Strategic Leadership & Talent Development: Develops, implements, and guides strategic direction for the Medicare Advantage actuarial function. Oversees, coaches, mentors, motivates, supports, and develops a cross-functional team, building specialized internal capabilities in Medicare Advantage pricing, Part D benefit economics, reserving, risk adjustment, healthcare economics, and advanced healthcare analytics. Oversees goal setting/review, regular guidance and 1-1 check-ins, career development/planning, upskilling, resource allocation, staffing, budget creation/management, succession planning, and other People & Culture programs/activities as needed. Fosters accountability, collaboration, and innovation to ensure organizational goals are met.
- Executive Business Intelligence & Plan Performance: Oversees and supports cross-functional alignment to ensure the best possible business intelligence and understanding of company financials in communications to executive team and the Essence Healthcare Board of Directors; delivers clear visibility into emerging Medical Loss Ratios (MLR), emerging claims trends, membership and revenue dynamics, member cohort profitability, risk score performance, and regulatory revenue shifts.
- MA Product Design & Pricing Architecture: Serves as the primary actuarial authority for Medicare Advantage product strategy and pricing. Partners with Health Plan Product, Clinical, Pharmacy, Network, Finance, and Market Growth leaders to evaluate Plan Benefit Packages (PBPs), supplemental benefits (e.g., dental, vision, hearing, OTC allowances), formulary and cost-sharing structures, service-area expansion, and specialized plan offerings. Balances member value, growth objective, competitive positioning, regulatory requirements, while achieving margin targets.
- Valuation, Reserving & Risk Management: Responsible for actuarial valuation for financial reporting functions. Oversees pricing and valuation for all Essence Healthcare plan offerings. Directs the estimation and review of unpaid claim liabilities (IBNR), premium deficiency reserves, and risk-sharing settlements in strict accordance with statutory accounting principles (SAP), NAIC guidelines, and CMS Minimum Medical Loss Ratio (85% MLR) standards. Enhances risk management, internal controls, and pricing policies/procedures.
- CMS Bid Strategy & Submission Execution: Leads the end-to-end development, actuarial modeling, review, documentation, certification, and HPMS (Health Plan Management System) submission of annual Medicare Advantage Part C and Part D bids, ensuring 100% on-time adherence to statutory CMS June deadlines and full compliance with CMS Bid Instructions, Call Letters, and Actuarial Standards of Practice (ASOPs). Establishes rigorous assumption governance, scenario testing, quality controls, executive review, and bid-to-actual monitoring. Ensures compliance across all activities.
- Regulatory Policy & Executive Strategy: Informs and participates in pricing strategy discussions with executive team. Interprets and models the financial impacts of CMS Advance Notices, Final Rate Announcements, county benchmark adjustments, and risk adjustment model changes (such as the transition from CMS-HCC V24 to V28). Partners with the VP of Risk Adjustment to align risk score progression forecasts with bid pricing assumptions. Develops and implements new pricing strategies and methods to adapt to market dynamics.
- Regulatory Financial Settlement & Guidance: Ensures all actuarial financial statement items are established in accordance with relevant actuarial, regulatory, and accounting guidance, including CMS Part D risk corridor reconciliations, low-income cost-sharing (LICS) subsidies, federal reinsurance settlements, and Risk Adjustment Data Validation (RADV) accruals.
- Governance, Quality Assurance & Audit Readiness: Oversees the creation of and adherence to all key processes, procedures, analyses, and techniques. Guides department adoption of best practices to minimize inaccuracies and ensure compliance with legal, regulatory, and business requirements, maintaining full audit readiness for CMS financial exams, RADV audits (in coordination with the Risk Adjustment team), and RAPS/EDPS encounter data reviews.
- Innovative Methodologies & Star Ratings Economics: Creates continuous improvement initiatives by monitoring industry trends and developing best-in-class tools and techniques that ensure application of innovative actuarial methodology and adoption of actuarial best practices. Collaborates with the VP of Quality and Stars Strategy to quantify and incorporate the financial implications of CMS Star Ratings (Quality Bonus Payments and rebate percentages) into long-term strategic plans and multi-year bid curves.
- Cross-Functional Partnerships & Value-Based Care Alignment: Forges strong, productive, collaborative, cross-departmental relationships and serves as liaison. Consults, influences, shares data review/results, and positively impacts the adoption of strategic, statistically-sound business opportunities.
- Actuarial Program Leadership: Provides strategic direction for the Company actuarial program, establishing consistent study time and other exam-related guidelines to foster credentialing (ASA/FSA/MAAA) across junior and mid-level actuarial staff.
- Performance Analytics & Executive Dashboards: Provides pricing analysis, reports, and dashboards to track the performance of various programs, maintaining detailed bid-to-actual variance analyses, inpatient/outpatient unit cost trends, and risk score trajectory tracking.
Qualifications
- Bachelor’s degree in Actuarial Science, Mathematics, Statistics, Economics, or related quantitative field.
- Fellow of the Society of Actuaries (FSA) and a Member of the American Academy of Actuaries (MAAA) in good standing, meeting the qualification standards to issue Statements of Actuarial Opinion and CMS Medicare Advantage Part C and Part D Actuarial Certifications.
- 15+ years of health actuarial experience with at least 7–10 years of direct, senior leadership experience in Medicare Advantage bid preparation, Part C/Part D pricing development, reserving, risk adjustment, and CMS health plan financial management.
- Significant executive leadership within a Medicare Advantage organization, health maintenance organization (HMO), or national managed care carrier (e.g., Humana, Devoted, UnitedHealth, or prominent regional MA plans), with direct exposure to executive leadership and governing boards.
- Expert understanding of CMS bid mechanics, HPMS filings, CMS-HCC and RxHCC risk adjustment models, Part D direct subsidy/formulary economics, Star Ratings financial mechanics, and statutory IBNR reserving.
- Excellent financial knowledge and deep understanding of the economics, actuarial, and accounting aspects of the health care industry, specifically value-based care delivery, capitation, two-sided risk sharing, and Medicare Advantage statutory balance sheet management.
- Proven ability to develop, support, coach, mentor, and empower a cross-functional team of credentialed actuaries, students, and healthcare economics data analysts.
- Highly skilled at developing pricing strategies and plans for new products and innovative services, including specialized MA plans (e.g., Chronic or Dual-Eligible SNPs) and consumer-centric supplemental benefit packages.
- Proven ability to work collaboratively across functional teams and different organizational levels to deliver results under strict, non-negotiable statutory timelines (e.g., annual June CMS bid deadline).
- Demonstrated ability to partner with sales and growth teams to evaluate Annual Enrollment Period (AEP) targets, geographic service area expansions, and competitive market positioning.
- Strong communication and negotiation skills, with demonstrated experience presenting complex actuarial models and financial trade-offs to Executive Leadership, Plan Leaders, and Board Committees.
- Ability to effectively organize and prioritize dynamic workflow during high-pressure bid cycles and regulatory filing windows.
- Ability to work with integrity, ethically and continuously uphold organizational values
- Excellent written and verbal communication skills with the ability to influence at all levels.
Working Conditions
- While performing the duties of this job, the employee works in normal office working conditions.
Disclaimer
- The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.
#LI-REMOTE
Pay Transparency:
Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.
The hiring range for this position is:
$175,300.00-$249,100.00
Benefits of working at Lumeris
- Medical, Vision and Dental Plans
- Tax-Advantage Savings Accounts (FSA & HSA)
- Life Insurance and Disability Insurance
- Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
- Employee Assistance Program
- 401k with company match
- Employee Resource Groups
- Employee Discount Program
- Learning and Development Opportunities
- And much more...
Be part of a team that is changing healthcare!
Member Facing Position:
No- Not Member or Patient Facing Position
Drug Screen Requirement:
No
MVR Required:
No
Credit Check Required:
No
Location:
Virtual – Microsoft Teams
Time Type:
Full time
Lumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.
Disclaimer:
- The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential job duties and responsibilities.
