Medicare Risk Adjustment Chart Review Jobs in Wisconsin

Medica is a nonprofit health plan with more than a million members that serves communities in Minnesota, Nebraska, Wisconsin, Missouri, and beyond. We deliver personalized health care experiences and partner closely with providers to ensure members are genuinely cared for.  

We're a team that owns our work with accountability, makes data-driven decisions, embraces continuous learning, and celebrates collaboration — because success is a team sport. It's our mission to be there in the moments that matter most for our members and employees. Join us in creating a community of connected care, where coordinated, quality service is the norm and every member feels valued.  

Actuaries use technical knowledge and business acumen to analyze financial experience, quantify financial risk, and project future medical expenses.  They are expected to adhere to the highest levels of ethics, professionalism, and standards of practice, as defined both internally and by the American Academy of Actuaries.  

The goal of the actuarial department is to be Medica’s source of truth for product financial performance and medical trend.  At all levels, this requires a commitment to producing complete, timely, and accurate actuarial analysis.  For more senior positions, this also requires the ability and willingness to work with the segments and help them meet their strategic goals and objectives. Performs other duties as assigned. 

Key Accountabilities 

• Conduct Experience Studies
  • Is familiar with the data and technology tools available to Medica’s actuarial department
  • Oversees the creation, development, and consistent production of accurate and timely actuarial information, reports, and exhibits
  • Reviews the work of analysts and other credentialed actuaries for reasonability, appropriateness, and relevance

• Quantify Risk
  • Works closely with segment leadership on product design, especially in areas of risk selection and induced utilization
  • Directs the work of analysts and/or consultants regarding key variables to stress during sensitivity testing
  • Communicates key variance in actual/expected financial performance to Medica and segment leadership
  • Incorporates the impact of risk adjustment into financial projections and performance analysis

• Provide Context
  • Works with Medica and segment leadership to create appropriate financial targets for pricing and product performance
  • Uses appropriate benchmarks when analyzing utilization and provider data
  • Provides the organization with appropriate value for actual/expected analysis, including intra-year targets for use by Medica leadership, segments, and corporate finance

• Forecast Financial Performance
  • Owns the actuarial component of all product pricing.  Works with segment leadership to incorporate actuarial, risk, competitive information, and aligning corporate and segment priorities around profit and growth
  • Ensures that forecast trend, revenue and membership projections are used appropriately by segment and corporate finance

• Filings & Compliance
  • Ensures rate filings and bids are accurate, submitted on time, and consistent with segment strategies and goals
  • Attends state negotiations and plenaries, as necessary. Oversees additional work to prepare for rate negotiations, including analysis by rate cell and geography

• Review the work of others
  • Reviews any low- and medium-risk actuarial work before it is published
  • Signs rate filings certifications, and other actuarial communications after appropriate level of review
  • Responsible for the timely and accurate monthly production of actuarial results – either specific to the segment, or corporate reporting as appropriate
  • Participates in segment activities, as directed by the General Manager.  This could include attending department meetings, having recurred 1:1 meetings, and providing status reports to segment leadership

Required Qualifications 

• Bachelor's degree or equivalent experience in related field
• 10 years of experience and 5 years of leadership experience

Required Certifications/Licensure 

• Fellowship in the Society of Actuaries (FSA)
• ASA with demonstrated performance over multiple years under the supervision of a qualified actuary
• Member, American Academy of Actuaries (MAAA,) Health actuarial or other related actuarial experience

Preferred Qualifications 

• Commercial health insurance experience, including fully and self-insured
• Experience with ACA 
• Experience with rate and premium setting

This position is an Office role, which requires an employee to work onsite, on average, 3 days per week. We are open to candidates located near one of the following office locations: Minnetonka, MN, or Madison, WI. 

The full salary grade for this position is $150,000– $257,200. While the full salary grade is provided, the typical hiring salary range for this role is expected to be between $150,000– $225,015. Annual salary range placement will depend on a variety of factors including, but not limited to, education, work experience, applicable certifications and/or licensure, the position's scope and responsibility, internal pay equity and external market salary data. In addition to base compensation, this position may be eligible for incentive plan compensation in addition to base salary. Medica offers a generous total rewards package that includes competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services and many other benefits to support our employees.  

The compensation and benefits information is provided as of the date of this posting. Medica’s compensation and benefits are subject to change at any time, with or without notice, subject to applicable law.  

Eligibility to work in the US: Medica does not offer work visa sponsorship for this role. All candidates must be legally authorized to work in the United States at the time of application. Employment is contingent on verification of identity and eligibility to work in the United States. 

We are an Equal Opportunity employer, where all qualified candidates receive consideration for employment indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic.