Director, EGWP Actuary

Location: Hybrid (Local to Denver, NYC, or Charlotte area) 

Position Summary: 

The Director, EGWP Actuary directs the strategy, governance, and operations of the EGWP actuarial function and serves as the accountable actuarial leader for the EGWP line of business. Reporting to the VP, Actuarial & Underwriting, this role holds a high degree of independence to formulate and administer actuarial policies and programs, make decisions regarding strategic direction, operational management, and budget, and oversee Medicare Part D pricing, bids, reserving, and monthly close. The Director builds and leads the EGWP actuarial team through subordinate managers and senior actuarial professionals, with full authority for hiring, performance management, promotions, and exits, and holds accountability for significant human and financial resources. Partnering with senior and executive leaders across sales, underwriting, EGWP, PBM, and finance, the Director translates business segment strategy into functional plans, makes final decisions on implementation, and is accountable for results that affect the financial performance of the line of business and the broader organization. This role requires deep actuarial expertise, strong business and financial acumen, and the ability to influence executive decision-making. 

Position Responsibilities: 

• Direct the development, maintenance, and ongoing enhancement of Medicare Part D financial models, including settlements, forecasting, and experience monitoring, through the actuarial team.  

• Set and approve the actuarial strategy and governance for EGWP bids, including assumptions, pricing recommendations, risk thresholds, and profitability targets, with final decision-making authority on implementation.  

• Partner with the VP, Actuarial & Underwriting and senior leadership to establish strategic plans and objectives for the EGWP line of business, translate business segment strategy into functional plans, and contribute to the development of organizational policies. 

• Own and approve the actuarial components of the monthly close process, including IBNR reserves, claims adjustments, and revenue estimates, and establish the controls and review standards the team follows. 

• Oversee experience analysis, trend forecasting, and risk assessments, and use the results to drive decisions that optimize the financial performance of the line of business. 

• Lead the underwriting strategy and process for a growing book of clients, ensuring compliance with CMS regulations and competitive market positioning. 

• Ensure emerging monthly experience is reconciled with models and approve assumption updates as needed. 

• Build and lead the EGWP actuarial function through subordinate managers and senior actuarial professionals, including organizational design, workforce planning, hiring, performance management, promotions, exits, and talent development. 

• Develop and manage the EGWP actuarial department budget and resource allocation, holding accountability for significant human and financial resources. 

• Monitor and evaluate CMS regulations, payment methodologies, and risk adjustment impacts related to Part D, and formulate the actuarial policies and programs needed to respond. 

• Oversee actuarial models, analytical capabilities, controls, and processes to ensure accuracy, scalability, and effective risk management. Provide technical direction on complex modeling and analysis of large healthcare datasets that support forecasting, reserving, and strategic decision-making.  

• Drive improvements to existing processes, automation of workflows, and enhancement of analytical capabilities across the function.   

• Serve as the recognized subject matter authority for EGWP and Part D financial matters. Present findings, recommendations, and actuarial concepts to executive leadership and key external stakeholders in a clear and concise manner.  

• Coach and develop managers and actuarial staff; set performance goals, conduct performance reviews, and make final decisions on hiring, promotions, and exits.  

• Actuarial professional responsibilities: Influences senior business partners by translating complex actuarial constructs into actionable recommendations; and initiating actuarial and financial advice in compliance with the Actuarial Standards of Practice. 

• Actuarial models: Establishes the standards, framework, and assumption-setting approach for new, existing, and non-traditional actuarial models to meet business needs. 

• Responsible for adherence to the Capital Rx Code of Conduct, including reporting of noncompliance. 

Required Qualifications: 

• Bachelor's degree in mathematics or related field AND minimum twelve (12) years of actuarial experience with deep experience in Medicare Part D.  Additional equivalent work experience in a directly related field may be substituted for the degree requirement.  

• Minimum six (6) years of people leadership experience with direct reports, including leading managers or senior professionals and managing a departmental budget.  

• Expert level experience in developing pricing as it relates to Part D EGWP. Understanding of the nuances and strategic importance of how each decision affects the overall bid. 

• In-depth knowledge of CMS bid processes, risk adjustment methodologies, and regulatory requirements. 

• Excellent communication and influencing skills, with a track record of presenting to and advising executive leadership. 

• A proactive and adaptable mindset, with the ability to thrive in an evolving and entrepreneurial environment. 

• Associate of the Society of Actuaries or Fellow of the Society of Actuaries  

Preferred Qualifications: 

• Prior EGWP experience
• Experience building or scaling an actuarial function in a growing or entrepreneurial organization. 
• Programming (SQL, SAS, Python, R) experience.