Job Listings

- Participate in the development, implementation, and measurement of clinical practice guidelines and quality programs, including drug-based (prescribing) guidelines, and disease-state-based guidelines. - Conduct analysis of medications for Quartz Drug Formulary to include critical evaluation of drug literature and FDA data, consultation with experts, consensus building amongst practitioners, analysis of impact on relevant populations, consideration of utilization management tools available and incorporation of economic data. - Participate in the...

- Analyze large datasets to uncover trends and risks - Build and maintain models for pricing, forecasting, and risk assessment - Conduct sensitivity analysis and scenario testing to evaluate the impact of different variables on financial projections - Design viable solutions by considering a wide range of data sources, tools, and techniques - Complete comprehensive data analysis and interpret results to support...

- Work with business and IT teams to design and deliver high-quality software solutions - Lead feasibility studies for new projects, including cost, time, and resource planning - Design and develop cloud-native applications using .Net, Azure Functions, and Azure Service Bus. - Ensure seamless integration across on-premises, third-party, and cloud applications -

- Perform audit so that errors or process issues not identified by the departments audited, are identified during quality audits. - Ensure all findings impacting external customers are identified and corrected to improve customer experience. Document findings accurately to support all audit observations to withstand critical scrutiny. - Complete root cause analysis by reviewing findings and formulate recommendations to mitigate future risk of trends. - Establish complex audit plans to effectively identify and mitigate...

- Conducting outreach to eligible members who need extra support, helping them understand and access available healthcare services. - Assess for social determinants of health, including but not limited to, social/family/caregiver support, housing needs, financial needs, and behavioral health needs. - Establish relationships and advocate for member services and needs with primary care providers and comprehensive care teams, including promotion of culturally appropriate care and services, and education on targeted P4P measures. -

- Medicare Advantage Bid Submission – overseepricing, forecasting, risk adjustment modeling, and rate filing. Influence decisions and contribute to strategic product-related decisions while navigating regulatory deadlines and requirements. - Team Leadership & Talent Development– Build, mentor, and lead high-performing team of Actuarial Analysts, fostering a culture of innovation, efficiency, and data-driven decision making through advanced analytics and insights. Provide thought leadership and mentor actuarial staff in complex analyses and predictive modeling. -

- Data Strategy & Architecture  - Maintain the data strategy documentation. - Influence data teams to optimize data management processes. - Design, develop, and maintain the organization’s enterprise data architecture. - Ensure that data architecture aligns with business goals and objectives. - Develop and implement information management...

- Provide expertise and support to external customers and internal teams and stakeholders, acting as a go-to-resource for pharmacy related inquiries. - Participates in the utilization review process, following departmental policies and procedures and state, federal and accreditation requirements. - Regularly performs audits & oversight of internal, PBM, and other vendor’s activities, including claims processing monitoring, web updates, configuration of criteria and...

- Design, implement, and oversee pharmacy benefit management strategies to optimize member outcomes and cost efficiency. - Leads relationship with PBM to understand contractual requirements and ensure vendor is meeting expectations. - Monitors reporting and analysis of delegated functions and any escalation of concerns for engagement and intervention - Performs complex research and analysis related to compliance with federal, state and local pharmacy regulations in order to support...

- Data Modeling & Architecture - Lead the design and development of Data Models. Create and maintain robust, scalable, and efficient logical and physical data models that support business intelligence, reporting, and advanced analytics within the health insurance domain. - Build and maintain data transformation pipelines within the analytics environment of the enterprise data warehouse. - Ensure that existing data models are continuously optimized for performance, scalability, and integration with evolving business...