Description
About Wilmington Health
Since 1971, Wilmington Health has been committed to the care and health of our community in Wilmington as well as all of Southeastern North Carolina. Wilmington Health is structured as a multi-specialty medical practice with primary care providers integrated into the system. In this way, Wilmington Health is able to provide a comprehensive and coordinated approach to the care of all our patients. Wilmington Health is committed to using collaborative, evidence-based medicine in providing the highest quality of care to the patients we serve.
Purpose:
The Actuary will own actuarial, financial, and analytical work related to healthcare value-based care arrangements, including ACOs, Medicare, Medicaid, Medicare Advantage, commercial risk contracts, and other population health programs. This is a credentialed actuarial role: the individual is expected to hold an ASA (or higher) designation and to exercise independent actuarial judgment, with accountability for the soundness of their own work product.
This position is responsible for analyzing healthcare claims, utilization, cost trends, risk adjustment, attribution, benchmarks, shared savings/loss opportunities, and performance under value-based care models. The Actuary works cross-functionally with finance, analytics, operations, clinical leadership, contracting, and executive stakeholders to identify financial opportunities, evaluate risk, support strategic decision-making, and communicate complex actuarial concepts clearly and actionably.
This role requires strong technical skills, healthcare data experience, and the ability to independently conduct and finalize actuarial analysis in accordance with applicable Actuarial Standards of Practice (ASOPs) and the Code of Professional Conduct. The role carries professional responsibility for its own actuarial conclusions.
Essential Duties/Responsibilities:
- Analyze medical claims, eligibility, attribution, provider, quality, and financial data to support value-based care performance evaluation.
- Develop and maintain actuarial models for total cost of care, medical expense trends, utilization, unit cost, risk adjustment, benchmark performance, and shared savings/loss projections across Medicare Shared Savings Program, ACO REACH, Medicare Advantage, Medicaid, commercial risk, and other value-based care arrangements.
- Analyze medical claims, eligibility, attribution, provider, quality, and financial data to support value-based care performance evaluation.
- Develop and maintain actuarial models for total cost of care, medical expense trends, utilization, unit cost, risk adjustment, benchmark performance, and shared savings/loss projections across Medicare Shared Savings Program, ACO REACH, Medicare Advantage, Medicaid, commercial risk, and other value-based care arrangements.
- Quantify the impact of changes in population, attribution, risk scores, benchmarks, rates, utilization, and medical cost trends.
- Evaluate performance by provider group, cohort, market, payor, contract, service line, diagnosis category, site of care, and other relevant segments.
- Identify medical cost and utilization opportunities, including avoidable admissions, emergency department utilization, post-acute care, specialist spend, pharmacy trends, chronic condition management, and care gap opportunities.
- Lead opportunity analyses for prospective partners, participants, or markets entering value-based care arrangements.
- Prepare financial forecasts, scenario analyses, sensitivity analyses, and performance projections to inform leadership decisions.
- Lead the financial evaluation of value-based care arrangements, including shared savings terms, downside risk exposure, benchmark assumptions, stop-loss considerations, and administrative fee structures.
- Monitor ongoing performance against budget, benchmark, expected trend, and contractual targets.
- Support reconciliation analysis for value-based care programs, including earned savings, losses, quality adjustments, risk score changes, attribution changes, and benchmark updates.
- Analyze risk adjustment data, including HCC/RAF trends, coding patterns, demographic factors, disease burden, and documentation opportunities.
- Develop reports, dashboards, and executive summaries that translate actuarial findings into clear business insights for clinical, operational, financial, and executive audiences.
- Partner with analytics, IT, finance, operations, clinical, and business leaders to define data needs, gather requirements, validate assumptions, and communicate findings.
- Contributes to the development and maintenance of actuarial data structures, reporting processes, and repeatable analytical tools.
- Communicate trends, issues, risks, and opportunities to management and proactively recommend next steps.
- Support special projects requiring actuarial research, healthcare financial analysis, market analysis, or value-based care modeling.
- Maintain a working knowledge of healthcare regulations, CMS programs, payor methodologies, value-based care models, risk adjustment, claims data, and reimbursement structures.
- Continuously assess existing analytical processes and recommend improvements to increase accuracy, efficiency, scalability, and usefulness of reporting.
- Develop and maintain internal actuarial methodologies, documentation, and assumptions, consistent with professional actuarial standards.
- Serve as an informal mentor to junior analysts, interns, or team members on actuarial methods, healthcare data, and analytical best practices.
- Perform other healthcare actuarial, financial, and analytical duties as assigned.
QUALIFICATIONS
Required Qualifications:
- Bachelor's degree in actuarial science, mathematics, statistics, economics, finance, data science, healthcare analytics, or a related quantitative field.
- ASA (Associate of the Society of Actuaries) credential required; FSA a plus.
- 3–5+ years of relevant experience in healthcare actuarial analysis, value-based care, health plan finance, provider finance, population health, or related work.
- Experience working with healthcare data, including claims, eligibility, provider, attribution, utilization, cost, quality, or risk adjustment data.
- Strong understanding of healthcare concepts such as total cost of care, PMPM, utilization, unit cost, risk scores, benchmarks, attribution, medical expense trend, revenue cycle, and value-based care performance.
- Working knowledge of Medicare, Medicaid, Medicare Advantage, ACOs, and value-based care contracting models broadly.
- Advanced Excel skills and experience working with large datasets.
- Experience with SQL required.
- Experience with one or more analytical tools or programming languages such as SAS, Python, R, or similar platforms.
- Experience with reporting or data visualization tools such as Power BI, Tableau, Looker, or similar platforms preferred.
- Strong quantitative, analytical, and problem-solving skills.
- Ability to interpret complex data and communicate findings clearly to non-technical stakeholders.
- Strong written and verbal communication skills.
- Strong attention to detail and ability to independently validate data, assumptions, and model outputs.
- Ability to manage multiple priorities, meet deadlines, and work independently while collaborating across teams.
- Ability to work in a fast-paced, team-oriented healthcare environment with evolving priorities.
Preferred Qualifications:
- FSA (Fellow of the Society of Actuaries) credential.
- Experience working at a health plan, provider group, ACO, CIN, MSO, population health organization, consulting firm, or healthcare analytics company.
- Experience with Medicare Shared Savings Program, ACO REACH, Medicare Advantage, Medicaid managed care, or commercial value-based care contracts.
- Experience analyzing CMS claims, payor claims, 837/835 files, attribution files, benchmark data, quality data, risk adjustment data, or reconciliation files.
- Experience developing financial opportunity analyses for value-based care partnerships or provider performance improvement.
- Experience leading actuarial modeling for shared savings, downside risk, stop-loss, trend, reserves, forecasting, or medical economics.
- Knowledge of HCC coding, RAF scoring, risk adjustment methodologies, quality measures, and CMS performance methodology.
- Experience building repeatable models, dashboards, and reporting packages for leadership review.
ADA Physical Demands:
Rarely (Less than .5 hrs/day) Occasionally (0.6 – 2.5 hrs/day) Frequently (2.6 – 5.5 hrs/day) Continuously (5.6 – 8.0 hrs/day)
Physical Demand
Required Frequency
Standing - Occasionally
Sitting - Continuously
Walking - Occasionally
Kneeling/Crouching - Rarely
Lifting - Rarely
Competencies
General
- Healthcare actuarial analysis
- Value-based care financial modeling
- Claims and utilization analysis
- Total cost of care analysis
- Medical expense trend analysis
- Risk adjustment and RAF analysis
- Benchmark and attribution analysis
- Shared savings/loss modeling
- Forecasting and scenario analysis
- Executive-level reporting
- Cross-functional collaboration
- Technical problem-solving
- Clear communication of complex quantitative findings