Position Overview

You are responsible as the steward of the Antidote health plan’s economic system, translating actuarial analysis into enterprise decisions that improve financial sustainability, member outcomes, and organizational performance. Rather than optimizing isolated metrics, the role identifies how interactions across pricing, care delivery, benefit design, provider incentives, and population health collectively determine Medical Loss Ratio (MLR) and long-term value creation. The role is reporting to the General Manager of the HMO.

Key Responsibilities

Medical Loss Ratio (MLR) System Leadership

Rather than simply reporting MLR performance, continuously evaluate how the organization’s economic ecosystem influences MLR.

• Monitor utilization, unit cost, premium sufficiency, emerging trends, catastrophic claims, risk adjustment transfers, and seasonality.
• Identify the underlying system interactions driving MLR performance rather than treating cost trends as isolated events.
• Distinguish between symptoms (rising costs) and structural causes (benefit design, provider incentives, member behavior, care access, operational workflows).
• Lead cross-functional initiatives involving Clinical, Network, Product, Finance, Operations, and Care Management to improve overall economic performance.

Population Health Economic

View population health as an integrated economic system where clinical outcomes, member engagement, provider behavior, and financial performance reinforce one another

• Analyze membership composition, morbidity, provider contracts, and health risk distributions
• Identify opportunities where improved clinical outcomes reduce long-term medical costs
• Recommend Quality Improvement Activities (QIA) that generate measurable improvements in both member health and financial performance
• Evaluate how interventions in one area influence performance throughout the organization

Integrated Actuarial & Financial Strategy

Use actuarial models to support enterprise decision-making rather than simply forecasting financial outcome

• Evaluate pricing strategies, benefit designs, network configurations, and risk adjustment scenarios as interconnected components of the overall health plan
• Model how product, provider, regulatory, and operational decisions interact over time
• Assess long-term sustainability instead of optimizing short-term financial metrics
• Support actuarial certifications and regulatory filings while ensuring consistency with the organization’s broader strategic objectives

Enterprise Systems Thinking

Serve as the quantitative integrator across the organization

• Translate actuarial insights into actionable business strategy
• Develop models that capture interactions across finance, clinical care, operations, provider networks, and member behavior
• Identify leverage points where relatively small interventions can improve multiple enterprise outcomes simultaneously
• Help executive leadership understand tradeoffs between cost, quality, growth, risk, and member experience

Qualifications Required

• 5–15 years of experience in health insurance, healthcare economics, actuarial analysis, management consulting, or population health
• Experience supporting ACA Marketplace, Medicare Advantage, Medicaid Managed Care, or commercial health insurance products
• Strong analytical and quantitative skills, with proficiency in SQL, Python
• Demonstrated ability to influence enterprise decisions through data-driven analysis, moving beyond reporting to strategic problem solving
• Experience partnering across Finance, Clinical, Network Management, Product, Care Management, and Operations
• Proven ability to translate complex analytical findings into clear, actionable recommendations for executive leadership
• Demonstrated ability to work independently, identify opportunities, initiate analyses, educate cross-functional teams, lead projects from concept through execution, and document playbooks
• Strong systems-thinking mindset with the ability to identify relationships, tradeoffs, and root causes across clinical, operational, and financial domains

Preferred Qualifications

• Bachelor’s degree in Actuarial Science, Economics, Mathematics, Statistics, Finance, Data Science, Operations Research, or a related quantitative discipline
• Master’s degree or Ph.D. in Economics, Health Economics, Public Health, Actuarial Science, Operations Research, Systems Engineering, or a related field
• ASA/FSA designation or meaningful progress toward actuarial credentials. Exceptional candidates with deep health economics expertise will also be considered
• Experience with health insurance operations, including enrollment, claims, provider networks, risk adjustment, and benefit design
• Working knowledge of NCQA accreditation, HEDIS, QRS, STAR Ratings, and other healthcare quality and performance measures
• Familiarity with healthcare regulatory requirements, including HIPAA, CMS regulations, and ACA compliance
• Experience in telehealth, digital health, value-based care, or other innovative healthcare delivery models
• Excellent communication, stakeholder management, and data storytelling skills, with the ability to influence technical and non-technical audiences

Competencies

Systems Thinking Competencies

• Recognize relationships across clinical, operational, financial, and regulatory domains
• Distinguish between root causes and downstream symptoms
• Understand how incentives shape behaviors across members, providers, employers, and regulators
• Build models that explain interactions, not merely isolated variables
• Balance short-term financial performance with long-term organizational sustainability
• Navigate ambiguity where multiple objectives and stakeholders must be reconciled

Leadership Competencies

• Ability to lead through influence across cross-functional teams
• Strong executive communication skills, translating complex analyses into clear business decisions
• Curiosity to investigate unexpected outcomes rather than accepting surface explanations
• Comfort challenging assumptions with evidence while remaining collaborative
• Sound judgment in balancing financial, clinical, regulatory, and member considerations

Desired Personal Attributes

• Thinks in systems rather than silos
• Sees patterns before others see metrics
• Is equally comfortable discussing actuarial models with actuaries and care management strategies with clinicians
• Connects financial outcomes to human behavior, clinical practice, operational processes, and policy
• Seeks leverage points—small changes that create broad organizational impact
• Views the health plan as an interconnected ecosystem whose performance emerges from the relationships among its parts