Budget and forecasting – HMOs

• Lead annual budgeting and planning process
• Manage cash flow and forecasting; direct all financial, project-based, and departmental accounting
• Monitor HMO capital levels on an individual company and consolidated level and escalate issues based on predefined internal metrics (i.e RBC, economic capital, etc)
• Monitor investments against HMO’s investment policy and internal capital levels
• Lead the data analysis efforts to identify business opportunities and issues with data quality, completeness, consistency, and accuracy, mainly on the Revenue (premium) analysis and medical costs data

Statutory Health insurance and GAAP reporting – Identify areas for 3rd party support and execution

• Ensure compliance with regulatory reporting requirements, including researching existing and new legislation, consulting with outside advisors, and filing financial reports
• Oversee accounts, ledgers, and reporting systems, ensuring compliance with appropriate standards and regulatory requirements
• Prepare and present financial reports and risk analysis
• Key liaison to external auditors and annual audit support
• Shared services chargebacks, transfer pricing, and Intercompany transactions
• Revenue (premiums) and medical costs recognition

Internal financial controls and financial stability

• Assist management in the development, implementation and monitoring of internal financial controls and corporate policies to maintain financial stability

Vendor and project management

• Conduct market research and identify prospective vendors to address organizational requirements
• Lead negotiations and implementation with vendors to address the functional requirements of an HMO
• Work in collaboration with the team to identify opportunities for business process improvement and support the implementation of such changes
• Lead the actuarial process with the 3rd party actuarial consultant for premium pricing, reserves, and proformas
• Work with executive management and 3rd party actuarial team on reinsurance programs, structures, marketing, contract negotiation, etc. (stop loss protection)

1. Hands-on with TPA management, Research, Analysis and Reporting

• Develop organization financial KPIs for HMO operations and performance and work in concert with the internal technical resources to operationalize a KPI dashboard
• Research, evaluate, and provide guidance on regulatory, compliance, and product design issues in partnership with the team
• Medical claims payments and analysis – and identification of opportunities for savings and efficiencies

Risk adjustment

• Oversee all risk adjustment processes, including developing workflows, tracking deadlines, and managing vendor contracts
• Work with business leaders and clinical teams to improve clinical documentation and claims submission processes
• Create work plans and ensure timely completion of projects
• Lead efforts to enhance coding, claims processing, and overall revenue cycle management
• Data Analysis: Evaluate risk adjustment strategies, perform root cause analysis, and develop interventions to improve outcomes
• Manage relationships with vendors supporting coding, billing, and collections
• Lead audit strategies and ensure compliance with regulatory requirements

Build and develop a high-performing accounting team over time that might include a combination of internal and external resources

Qualifications

Educational Requirements:

• A bachelor’s degree in finance, accounting, economics, or a related field is required
• A CPA, CFA, or ACCA would be a strong advantage

An MBA or a master's degree in finance or accounting is an advantage

Experience:

• At least 7-10 years of experience in finance, with a significant portion within the health insurance industry
• Deep understanding of the health insurance sector (specifically ACA, small and large groups, ICHRA), including regulatory requirements and financial management practices – must have

Skills:

• Ability to develop and implement financial strategies that align with the organization's goals
• Strong analytical and problem-solving skills, with proficiency in financial modeling and data analysis
• Proven leadership and team management skills, with the ability to mentor and develop finance teams
• Excellent communication and interpersonal skills to effectively collaborate with senior management and other stakeholders
• In-depth knowledge of financial regulations and risk management strategies
• Familiarity with platforms such as NetSuite (ERP tool), Zuora, and PaymentTech is an advantage