Fallon Health

  • Actuarial Analyst - Growing health Insurance Company.

    Location US-MA-Worcester
    Posted Date 2 months ago(1/14/2019 10:52 AM)
    Job ID
    # Positions
  • Overview

    About Fallon Health

    Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.


    Brief summary of purpose:


    The primary role of the Actuarial Consultant will be to function as the Medicare Advantage financial analyst for the Actuarial Services department. The AC will take the lead in the data collection, analysis and completion of the annual CMS MA Part C and Part D bid submission filing process. These responsibilities will include, but not be limited to, working with the Sr. Director and Actuary, Government Programs and external actuarial consultants to provide detailed reporting of product experience and to support development of medical trends and evaluation of benefit differences. The AC will be very familiar with CMS regulations applicable to the bid and the product and will take a lead role in developing responses to desk review and audit questions.


    The Actuarial Consultant will be familiar with all revenue streams relevant to our Medicare Advantage products and will work with the Risk Analytics team to understand changes in Fallon’s risk scores over time and to recommend ways to optimize risk adjusted revenue.


    The Actuarial Consultant will also support the Senior Care Sales team in developing pricing for individual and group Medicare Supplement products and Employer Group Waiver Plans (EGWP). The AC will also provide consultative support for these products to the Sales team, respond to RFP/RFI requests and attend client meetings as necessary.


    This role will be responsible for working with IT to serve as the business SME to drive development of automated medical loss ratio reporting from the company’s EDW. The AC will also complete any CMS/DOI reporting requirements related to Fallon’s senior plan products, including the annual CMS Medical Loss Ratio reports. The Consultant will also work with the Government Programs Actuary, product line management, Medical Economics and Care Services to provide analysis and recommendations to improve product performance.


    The AC will represent the Government Programs Actuary and department in corporate meetings as required. The Actuarial Consultant will participate in corporate project workgroups and team initiatives as assigned. The position will also be responsible for the direction and completion of other projects, data oversight and analyses as needed to solve business problems and improve business processes.


    Major areas of responsibility and accountability:


    Medicare Advantage bid process

    • Actively participate on corporate bid team
    • Respond to requests from external consultants for data
    • Maintain accurate records of work and develop process documentation
    • Manage CMS/HPMS software
    • Enhance EGWP pricing model and provide account specific rates

    Product Line support

    • Educate product line management on drivers of variances from budget for all revenue streams
    • Meet regularly with the product line manager to identify and implement reports to improve product performance and identify opportunities to enhance revenue
    • Medical loss ratio reporting for Medicare Advantage, PACE and SCO products

    Medicare Supplement product pricing

    • Develop standard pricing for individual and group Med Supp products
    • Provide experience-based rates to large group prospects and renewals

    Corporate Project support

    • Participate in corporate projects and subgroup meetings. Complete analyses related to corporate projects and business needs as required.




    • BA or BS – Mathematics, Finance, Economics, Management, other





    • Experience in managed health care financial analysis. Familiarity with Medicare Advantage and/or Part D preferred.
    • Support role: Actuarial, Finance, Accounting, Regulatory, Enrollment, Claims – other
    • Advanced Excel skills
    • SQL- Navigator and/or SAS experience
    • Ability to create presentations & exhibits in formats that meet various audience level

    • 10 years – Managed Care setting
    • 8 years - Excel
    • 5 years – SQL/SAS Experience




    Ability to communicate effectively and in a professional manner in both written and verbal form.





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