Consultant
We are seeking a Health Actuarial Consultant with deep experience in value-based care (VBC) to help payers, provider groups, and risk-bearing entities design, evaluate, and optimize risk contracts. You will translate claims, clinical, and utilization data into actionable financial insights and contracting strategies-covering shared savings/loss models, capitation, bundles, and global risk. Ideal candidates blend strong actuarial and financial modeling skills with a practical grasp of provider operations, population health, and care management economics.
What You'll Do
VBC Contracting & Pricing
- Design and price VBC arrangements (e.g., shared savings/loss, partial/full capitation, episodic bundles, PMPM care management fees) including risk score normalization, trend, and credibility adjustments.
- Develop benchmarks and settlement methodologies (risk adjustment, quality gates, attribution logic, outlier/stop-loss definitions).
- Build financial models to simulate performance under multiple scenarios and inform deal terms and negotiation strategy.
Medical Economics & Performance Analytics
- Evaluate total cost of care and utilization patterns; identify cost drivers and savings opportunities (site-of-care shifts, leakage, avoidable utilization, specialty spend).
- Build and maintain performance dashboards (cost, quality, access) to guide operational actions for client/provider partners.
- Conduct IBNR estimation, reconcile settlements, and produce monthly/quarterly financial reporting packages.
Risk Adjustment & Quality
- Assess RAF/HCC and other risk score methodologies for accuracy and completeness; quantify financial impact of documentation/coding and care gap closure initiatives.
- Analyze quality measure performance (e.g., HEDIS, Medicare Star Ratings) and model incentive/withhold implications on shared savings.
Population Health & Care Model ROI
- Quantify ROI for care management programs, pharmacy interventions (formulary/UM, medical vs. pharmacy benefit), and high-risk cohort initiatives.
- Segment populations and build predictive risk models to target interventions (high-cost claimants, chronic conditions, rising risk).
Client Advisory & Execution
- Lead workstreams, manage timelines, and mentor analysts; present findings to executive and clinical stakeholders (CFO, CMO, population health leaders).
- Translate analytics into clear recommendations and implementation plans that improve contract performance and operational outcomes.
FAQs
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