Actuarial Risk Adjustment Jobs in Florida (NOW HIRING)

Location Address:

9521 San Mateo NE Albuquerque, NM 87113-2237

Summary:

The VP Chief Actuary is the senior leader responsible for actuarial services, underwriting, pricing, reserving, forecasting, and insurance risk management. This role contributes to the financial soundness of the health plan, provides strategic insight to executive leadership, and oversees all actuarial and underwriting functions supporting government and commercial lines of business. The Chief Actuary serves as the Appointed Actuary and is accountable for regulatory compliance, actuarial governance, and the development of actuarial talent.
Work Arrangement:
Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY.
Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

Job Description:

Key Responsibilities:

Product and Pricing Strategy
A. Evaluate and Promote Medicaid Rate Adequacy & State Partnership
Oversee evaluation of capitation rate assumptions.
Partner directly with the state Medicaid agency to ensure assumptions are reasonable, risk is managed, and rates are actuarially sound.
Support rate negotiations and data submissions to the state and CMS.
Analyze the impact of risk adjustment models, acuity shifts, redeterminations and eligibility churn, directed payments and supplemental payment programs, changes in covered benefits, eligible population, and provider payment schedule changes.

B. Ensure Commercial and Medicare rates balance competitiveness and adequacy, and comply with applicable regulatory standards
Set premium rates for individual, small group, large group, and government programs (e.g., Medicare Advantage, Affordable Care Act marketplace plans).
Oversee trend analysis (medical cost inflation, utilization changes, provider contracting impacts).
Approve final rate filings submitted to state and federal regulators.

C. Product Development, Underwriting and pricing
Partner with product, underwriting, and finance teams to support new product design and market expansion.
Supervise the underwriting team
Maintains and updates pricing models to evaluate rating impact of regulatory changes and benefit plan changes

Financial Oversight & Forecasting
Oversee actuarial balance sheet items:
o Claims liability reserves (IBNR) estimation
o Provider incentive payments or receivables
o Premium deficiency reserves
o Risk corridor payables/receivables
o Risk adjustment revenue projections
Partner with finance team on forecasting
Lead actuarial analytics teams.
Analyze and explain drivers of rolling trends in claims experience, provider contract performance, pharmacy costs, and population health metrics

Regulatory & Statutory Accountability
Sign statutory actuarial opinions.
Interface with:
o State Department of Insurance
o State Medicaid agency
o Centers for Medicare & Medicaid Services
Oversee compliance with Medicaid managed care rate certification standards.
Ensure adherence to minimum MLR requirements.
Certify compliance with mental health parity quantitative treatment limits
(Oversee commercial product risk adjustment submissions and validation)
Governance & Talent Leadership
Maintain actuarial standards (e.g., compliance with the Actuarial Standards of Practice).
Recruit and develop actuarial leadership.
Maintain relationships with external auditors and consulting actuaries.

Additional Job Description:

Qualifications

BA or BS in actuarial science, math, or og
Fellow of the Society of Actuaries (FSA) or Associate of the Society of Actuaries (ASA) required; Member of the American Academy of Actuaries (MAAA) required.
10+ years of actuarial experience in health insurance, with significant leadership responsibility.
Extensive knowledge of and experience in Medicaid
General knowledge and experience in Medicare Advantage, ACA, and/or commercial health markets
Expertise in pricing, reserving, forecasting, and regulatory filings.
Strong executive communication skills and ability to influence senior leadership.
Proven ability to lead teams and manage complex, multi stakeholder initiatives.
Preferred Attributes
Experience in value based care, risk adjustment, and population health analytics.
Background in enterprise risk management or capital strategy.
Ability to translate complex actuarial concepts into actionable business insights.
Strategic thinker with a bias for collaboration and innovation.
Demonstrated ability to develop practical solutions and drive outcomes

Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
• Continuing education and career development opportunities
• Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system ofnine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
We are part of New Mexico's history-and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.