Director - Risk Management - Avera Health Plan

Avera Health

Location:

Avera Health Plans

Worker Type:

Regular

Work Shift:

Day Shift (United States of America)

Position Highlights

JOB INFORMATION

Job Title:

Director - Risk Management & Actuarial Services - Avera Health Plan

Job Code:

AVH1253

FLSA Status:

Exempt

Job Profile Pay Rate Type:

Salary

Date Revised:

2/13/2025 9:06:44 AM

Job Category:

Non-Patient Care

General Hours Worked:

Primarily days with possible weekends/evenings/holidays

Job Family:

Leadership

Union Membership:

Job Summary

The Director of Risk Management & Actuarial Services leads the risk assessment, actuarial analysis, and premium rating functions for Avera Health Plans. This role ensures financial sustainability and compliance while supporting pricing strategies, claims analysis, and forecasting for the health plan. The position collaborates with leadership to manage financial risks, optimize operations, and maintain regulatory compliance.

JOB FUNCTIONS

Essential Functions

Essential Job Functions

•

Develop and implement strategies for identifying, evaluating, and mitigating financial and operational risks.

•

Oversee risk management initiatives, including liquidity stress testing, and risk modeling and advise executives on risk exposure, financial stability, and long-term sustainability.

•

Monitor industry trends, regulatory changes, and emerging risks to advise leadership on proactive measures.

•

Lead the development of actuarial models to project claims, analyze trends, and support financial planning.

•

Ensure accurate pricing strategies and rate filings in compliance with regulatory requirements.

•

Provide actuarial support for underwriting, product development, and cost containment initiatives and collaborate with Finance and Operations to evaluate claims reserves.

•

Drive decision-making by presenting clear, data-driven insights to leadership.

•

Support strategic initiatives including new product development and expansions, by providing actuarial and risk analysis.

•

Ensure compliance with state and federal regulations related to risk management and actuarial practices and act as a liaison with external auditors, regulators, and stakeholders on actuarial and risk matters.

•

Lead, mentor, and develop a team of actuaries and risk management professionals.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Supervisory Responsibilities

Yes

Supervisory Responsibilities

Responsibilities include interviewing, hiring, developing, training, and retaining employees; planning, assigning, and leading work; appraising performance; rewarding and coaching employees; addressing complaints and resolving problems.

No

Education

Education Level

Education Details

Required/
Preferred

Bachelor's

Actuarial Science, Mathematics, Finance, or a related field

Required

Master's

Actuarial Science, Mathematics, Finance, or a related field

Preferred

License/Certification/Registration

Licenses/Certifications

Licenses/Certification Details

Time Frame

Required/
Preferred

Fellow of the Society of Actuaries (FSA) - Society of Actuaries (SOA)

Upon Hire

Required

or

Associate of the Society of Actuaries (ASA) - Society of Actuaries (SOA)

Upon Hire

Required

Certification in Enterprise Risk Management (CERA) - American Society for Health Care Risk Management (ASHRM)

Preferred

Experience

Experience

Experience Details

Required/
Preferred

4-6 years

Actuarial or risk management experience in the health insurance industry.

Required

1-3 years

Leadership or management experience.

Required

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily. The requirement listed above are representative of the knowledge, skills, and/or abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Physical Demands and Working Environment

Label

Short Description

Full Description

Sedentary

Very light physical requirements

Sedentary Work- Exerting up to 10 pounds of force occasionally (occasionally means activity or conditions exist up to 1/3 of the work day), and/or, a negligible amount of force frequently (frequently means activity or condition exists from 1/3 to 2/3 of the work day) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working Environment - Choose which statements apply:

X

May be exposed to communicable diseases when working in a healthcare environment.

X

The noise level in the work environment is usually moderate.

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

Develops and designs and executing an effective risk assessment strategy that is aligned to the strategic goals & objectives of Avera Health Plans in collaboration with the CFO. Leads the preparation of financial projections, annual rate filings and underwritten quotes in support of the Avera Health Plans risk assessment strategy. Directs the reinsurance and stop loss quoting process for risk products and self-funded clients respectively. Leads Avera Health Plans Affordable Care Act Risk Adjustment program to optimize effectiveness and return on investment. Seeks out ways to advance automation in the risk assessment and quoting process.

What you will do

• Leads the development of statutory rate filings for all Avera Health Plans products which includes the oversight of and collaboration with outside consulting actuaries as well as internal stakeholders.
• Develop and advises leadership on risk strategy that is appropriate for Avera Health Plans.
• Develop and carry out an effective risk assessment approach including adherence to compliance issues in the following areas: Current and prospective risk based products and underwriting current and prospective groups.
• Serve as Avera Health Plans Affordable Care Act (ACA) Risk Adjustment (RA) leader/owner including but not limited to coordination with legal, IT, actuarial and clinical functions as they pertain to RA including compliance, forecasting and reserving of annual receivable/payout.
• Oversees the annual Risk Adjustment cycle are completed successfully including, but is not limited to: EDGE Server, Supplemental RA analytics, Risk Adjustment Data Validation (RADV), Prospective member outreach and Retrospective chart reviews.
• Facilitates timely stop loss quoting for incumbent and prospective self-funded clients, negotiating pricing and assisting with accurate proposal delivery, in collaboration with reinsurance partners. Supports clients with appropriate funding level recommendations, and other reporting as needed.
• Directs Avera Health Plans annual reinsurance coverage renewal and oversees reinsurance claims administration for all self-funded and insured lines.
• Compliance with federal and state statutes, including, but not limited to, provisions outlined within the Patient Protection and ACA.
• Review business intelligence systems periodically, identifying areas of emerging trends that warrant additional review by the medical economics committee. Strategically support the generation of data/information, analysis and assessments/judgments for budgeting, forecasting and projections as needed.
• Seek out ways to advance automation in the risk assessment quoting process to support efficient underwriting of incumbent and prospective groups during peak volumes periods during the year.
• Responsibilities include interviewing, hiring, developing, training, and retaining employees; planning, assigning, and leading work; appraising performance; rewarding and coaching employees; addressing complaints and resolving problems.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Bachelor's in Finance, Actuary Science or related field.
• 4-6 years of related experience.

Preferred Education, License/Certification, or Work Experience:

• Financial analytics experience.

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part-time and full-time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO front-loaded for eligible hires

• Free health insurance options, for full-time single coverage on Avera High Deductible Health Plan

• Up to 5% employer matching contribution for retirement

• Career development guided by hands-on training and mentorship

Applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-or send an email to .