Formulate and apply mathematical modeling and other optimizing methods to develop and interpret information that assists executive management with decision making, policy formulation, or other managerial functions as it relates to the products and services of a multiple employer welfare arrangement trust (MEWA), Western Growers Assurance Trust (WGAT), and a third-party administrator (TPA), Pinnacle Claims Management, Inc. (Pinnacle). The changes to pricing or products can include fully-funded employer sponsored health care, pharmacy costs (pricing structure and rebates), third party administer fee structure and other related ancillary products. May collect and analyze data and develop decision support software, services, or products. Position reports to the Chief Operating Officer (COO) and has no direct reports.

Qualifications

• Bachelor's Degree in Statistics, Computer Science, Mathematics, Economics, Actuarial Science, or a related field seven to ten years of experience in analyzing and modeling risk with health plans across various group sizes (large and small group) and funding (fully insured, self-insured, and partially self-insured) preferred.
• Expert level understanding of healthcare claims taxonomy, billing procedures, and reporting standards across the insurance industry.
• Experience in healthcare analytics platforms such as Springbuk and Cedargate Technologies.
• Proven ability to analyze the cost benefit of changing the structure of health benefits.
• Certified Employee Benefits Specialist (CEBS) or similar designation required.
• Resident in California a must.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.  
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).  
• A designated room for home office or steps taken to protect company information (e.g., facing computer towards wall, etc.)  

 

Duties And Responsibilities

• Summarize and present to internal and external stakeholders’ health plan financial results identifying trends, cost drives, outliers, and present predictive models on future claims and expenses.
• Present ways to reduce the cost of claims and ultimately health costs to the client/member
• Suggest ways to design the plans to garner savings in expenses or improvement in benefits to participants
• Provide analysis of impact of potential plan changes under consideration, weighing financial outcomes with their probability and impact to participants experience
• Evaluate and make recommendations on vendors providing point solutions

• Support WGAT underwriting with renewal and proposal calculations.
• Present ways to reduce the cost of claims and ultimately health costs to the client/member.
• Suggest ways to design the plans to garner savings in expenses, determine contract rate trends with providers
• Alert senior executives in e.g. COO and chief financial officer (CFO) of external forces impacting the cost of coverages.

• As a valued partner present potential prospects as the key subject matter expert in benefits analytics to promote sales for both fully funded WGAT and self-funded Pinnacle clients. In addition, be available for expert consultation for existing clients to ensure client satisfaction and retention.  Partner with the Underwriting Department Colleagues 
• Work with the Underwriting team and blend into the underwriting discussions, be a change agent in how the organization views claims.
• Get curious and use the Company’s data and systems to drive predictive modeling conversations for the purpose of plan change recommendations to the client. 
• Use data analytics in a fresh way to determine trends and predictive modeling.

• Determine what the competitors are doing in the same products and services space and in different geographical areas around the State.
• Find and report what the large carriers are doing relative to the pricing and services with the different metal plans. Make suggestions to recalibrate the WGAT and PCMI products relating to coverage, co-pay, deductibles.  
• Every year make a well-informed and researched recommendation to recalibrate the metal tiers.
• Find ways to drive lower costs and present them to the COO and CFO, at the same time guarding against losing competitive advantage in the marketplace.
• Make suggestions to plan designs to move patients to outpatient care when appropriate. 

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.  
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data 
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).

 

• All other duties as assigned.

Physical Demands/Work Environment