Finance Manager/Head of Finance - HMO

Key Responsibilities

Statutory Health Insurance and GAAP Reporting

• Ensure compliance with federal, state, and local regulatory reporting requirements, including researching current and new legislation, consulting external advisors, and filing accurate financial reports.
• Oversee accounts, ledgers, and reporting systems to ensure adherence to applicable standards and regulatory requirements.
• Prepare and deliver financial reports and conduct risk analyses.
• Maintain relationships with external auditors, addressing their findings and recommendations.
• Manage shared services chargebacks, transfer pricing, and intercompany transactions.
• Oversee revenue (premiums) and medical cost recognition processes.

Budgeting and Forecasting for HMOs

• Lead the annual budgeting and financial planning processes.
• Manage cash flow and forecasting, and oversee all financial, project-based, and departmental accounting activities.

Internal Controls

• Design and monitor internal controls to safeguard financial security.
• Contribute to corporate policy development as part of the senior management team.

Vendor and Project Management

• Conduct market research to identify vendors that meet organizational needs.
• Lead negotiations and manage vendor implementation to fulfill HMO-specific requirements.
• Collaborate with internal teams to identify and implement business process improvements.
• Oversee the actuarial process with third-party consultants for premium pricing, reserves, and proformas.
• Manage the reinsurance policy, including stop-loss protection.

Third-Party Administrator (TPA) Management, Research, Analysis, and Reporting

• Develop financial KPIs for HMO operations and collaborate with technical teams to create a KPI dashboard.
• Research and provide guidance on compliance, regulatory issues, and product design.
• Analyze medical claims payments to identify cost-saving and efficiency opportunities.

Risk-Based Capital (RBC) and Investment Policy Management

• Manage RBC requirements and oversee the HMO’s investment policy.

Data Analysis for Business Opportunities

• Lead data analysis efforts to address issues with data quality, accuracy, and consistency, particularly for revenue (premium) and medical cost data.

Risk Adjustment

• Oversee risk adjustment workflows, track deadlines, and manage vendor contracts.
• Collaborate with business and clinical teams to improve documentation and claims submission processes.
• Develop work plans and ensure timely project completion.
• Enhance coding, claims processing, and revenue cycle management practices.
• Conduct data analyses to evaluate risk adjustment strategies and improve outcomes.
• Manage vendor relationships for coding, billing, and collections, ensuring compliance with regulatory requirements.
• Recruit, mentor, and develop a strong accounting and finance team over time.

Qualifications

Educational Requirements:

• Bachelor’s degree in finance, accounting, economics, or a related field (required).
• CPA, CFA, or ACCA certification is strongly preferred.
• MBA or master’s degree in finance or accounting is advantageous.

Experience:

• 7–10 years of experience in finance, with significant time spent in the health insurance sector.
• Deep knowledge of the health insurance industry, including ACA, small and large groups, and ICHRA regulations (mandatory).

Skills:

• Expertise in developing and implementing financial strategies that align with organizational goals.
• Advanced analytical and problem-solving skills, including financial modeling and data analysis.
• Proven leadership capabilities and team management skills, with experience mentoring finance professionals.
• Excellent communication and collaboration skills to work effectively with senior management and stakeholders.
• Thorough understanding of financial regulations and risk management practices.
• Familiarity with tools such as NetSuite (ERP), Zuora, and PaymentTech is a plus.