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 Manager of Risk Adjustment and Trend Analytics is a key member of the Finance management team. Under supervision of the V.P of Financial Planning and Performance Analysis, the Manager oversees risk adjustment analysis primarily related to the MassHealth Medicaid and New Hampshire Medicaid lines of business, directly impacting and improving the revenue for these products. The Manager also leads 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.

Our Investment in You:

* Full-time remote work

* Competitive salaries

* Excellent benefits

Key Functions/Responsibilities:

Risk Adjustment responsibilities include:

• Represent finance as a key member of risk coding work group and risk coding steering committee.
• Periodically validate member-level risk scores and work with state agencies to resolve significant discrepancies.
• Ensure that we have most current version of risk adjustment software / models, evaluating the impact of version changes, and summarizing new risk weights for the risk coding team.
• Support downstream implementation of risk adjustment, including trend normalization, and validating normalized risk scores used in profitability and forecast models.
• Evaluation and tracking of differences between risk adjustment factors loaded in the DW vs those used for risk adjustment of cap revenue, including r-square analysis and tracking of version changes.
• Support system risk coding efforts, including normalization impact on ROI.
• Support advocacy efforts with state agencies when risk model changes are proposed, including evaluation of impact on our populations and identifying potential biases for specific sub-populations.

Trend Analytics responsibilities include:

• Lead monthly trend meetings for each of the 4 lines of business with product owners and finance leaders, looking for opportunities to reduce medical costs through performance initiatives. Coordinate trend summaries, as needed, with the actuarial services team for QHP and SCO products and/or vendor related trends.
• Trend analytics include PMPM, cost per use, and utilization / 1000 metrics, rate vs volume variances, unit cost vs severity, rating category dimensions, and normalization based on acuity and known unit cost changes. Provider profiling is performed at servicing provider level and at member PCP levels. Control for services which are fully at-risk vs those that are pass-through, and changes between sub-capitation and FFS arrangements.
• Incorporate medical expense benchmarks relative to pricing benchmarks set forth by state actuaries. Identify which services are above or below pricing benchmarks. Work with business leaders to close the gaps.
• Coordinate with the provider analytics team to maintain unit cost trend history for use in normalizing the cost per use component of trends.
• Serve as a key member of the Under/Over Utilization Management (UOUM) meetings. Present utilization metrics spanning the 4 lines of business, looking for opportunities of UM savings, and coordinate drill-downs with actuarial and provider analytics teams.
• Oversee maintenance and distribution of the monthly Medical Expense Report (MER) database, including the monthly trend dashboard and underlying rolling12 trend reports.
• Work with other finance leaders to adjust and adapt trend reports for key population, program and/or environmental changes. Examples include large membership changes, fee schedule changes, PBM recontracting and services moving from at-risk to carve-out.

Other Functions/Responsibilities:

* Directs a team of health care analysts/analytic managers using SAS and other query languages for data mining, reporting, evaluation and outcomes measurement. Lead analysts in the design, development and implementation of evaluation methods and tools to measure the effectiveness of both internally developed medical management initiatives or externally purchased vendor programs.

* Responsible for staff hiring, work allocation and scheduling, training and professional development, performance management and related supervisory activities.

Supervision Exercised:

* Manages up to 4 staff.

Supervision Received:

* General supervision is received weekly.

Qualifications:

Education:

* Bachelor's Degree in Mathematics, Actuarial Science, Finance, Economics or related field required; Associate of Society of Actuaries (ASA).

Preferred/Desirable:

* Master's Degree preferred.

* Background in managed healthcare, insurance operations

* 2+ years of prior experience managing team of analyst

* Fellow of the Society of Actuaries (FSA) Preferred.

Experience:

* A minimum of five years of progressively responsible experience in, actuarial analysis, health care analytics trend analysis, risk adjustment analysis, data modeling, informatics or similar analysis. Commensurate educational experience in related field will be considered.

* Working knowledge of at least one of the following risk adjustment methodologies DxCG, CDPS+Rx, CMS Medicare Advantage HCC Model, ACA HCC Model.

Competencies, Skills, and Attributes:

* Expert analyst with an ability to translate findings into actionable opportunities.

* Proficiency working with risk adjustment models.

* Ability to use well developed interpersonal skills to lead and direct the efforts of others, both internally and externally required.

* Proficient in excel, SQL and SAS or other statistical software.

* Working knowledge of MS tools, including MS Office products, MS Access, MS Project.

* Must be able to conceptualize and envision the impact of change, and propose new ways to do business.

* 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.

Certification or Conditions of Employment:

* Pre-employment background check

Working Conditions and Physical Effort:

* Regular and reliable attendance is an essential function of the position.

* Work is normally performed in a typical interior/office work environment or remotely.

* 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