Description
Analyze healthcare claims and utilization data to model morbidity, forecast medical costs, and quantify risk for health insurance and managed care products. Set premiums, reserves (including IBNR), and capital to ensure solvency, competitiveness, and regulatory compliance.
- • Analyze medical and pharmacy claims to estimate morbidity, utilization, and cost trends.
- • Price health products including individual, small and large group, Medicare Advantage, Medicaid, and exchange plans.
- • Design and review benefit structures and policy provisions, and calculate premiums and member cost sharing.
- • Perform reserving analyses (e.g., IBNR, claims development, contract reserves) and assess liabilities for future benefits.
- • Build predictive models and credibility studies for risk scoring, cost forecasting, and care management targeting.
- • Prepare and file rate submissions and actuarial memoranda with state regulators and CMS; support MLR compliance.
- • Conduct risk adjustment analyses (e.g., HHS and CMS-HCC), monitor RAF scores, and project transfer payments.
- • Evaluate provider contracts, capitation rates, and value-based payment arrangements; set risk-sharing settlements.
- • Collaborate with underwriters, clinicians, data scientists, finance, and product teams on new and existing health products.
- • Monitor emerging experience (e.g., specialty pharmacy, behavioral health) and recommend pricing or benefit changes.
- • Design and negotiate reinsurance and stop-loss structures to manage catastrophic and high-cost claimant risk.
- • Advise clients as a consultant on pricing, reserving, product strategy, and regulatory issues.
- • Communicate actuarial findings to executives, regulators, shareholders, policyholders, and the public.
- • Testify before public agencies on health policy and rate matters when required.
- • Provide expert witness opinions on lifetime medical costs, lost earnings due to illness or injury, or health-related liabilities.
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Financial Services
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
