<p>Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.</p> <p>Who Are We?</p> <p>Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.</p> <p>Why Join Us?</p> <p>We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.</p> <p>Position Summary</p> <p>The Senior Vice President (SVP), Health Care Economics serves as the strategic leader responsible for driving financial performance, provider value, clinical cost optimization, and enterprise decision-support. This executive oversees medical cost management, actuarial and forecasting functions, clinical performance and predictive analytics, provider network financial strategy, risk adjustment, and Stars performance economics. The SVP partners closely with Clinical and Pharmacy Operations, Network Management, Product, Actuarial, Finance, FP&A, and Compliance leadership to ensure sustainable growth, strong unit cost performance, and competitive benefit design within CMS regulations. Directly supervises the analytic and actuarial teams focused on membership, revenue, and health care cost analytics, reporting & forecasting. This role is a key member of the executive leadership team and directly influences enterprise strategy, profitability, and long-term market competitiveness.</p> <p>Key Responsibilities</p> <p>Strategic Leadership & Enterprise Performance</p> <ul> <li>Develop and execute the enterprise medical economics strategy, ensuring alignment with organizational goals and CMS requirements. </li><li>Lead comprehensive cost-of-care strategies, including utilization management analytics, value-based care financial models, and provider performance optimization. </li><li>Provide executive oversight of medical cost projections, trend analysis, forecasting, and budgeting. </li><li>Lead Clinical Affordability initiatives including monthly meetings and tracking to assure utilization, place of service, pharmacy optimization, contracting, and payment integrity initiatives are fully leveraged to support attainment if MLR objectives. </li><li>Serve as the organization's senior expert on health care economics, advising the President/CFO, MCFO, and executive team on key cost drivers and financial levers. </li></ul> <p>Medical Cost Management & Optimization</p> <ul> <li>Oversee analysis of inpatient, outpatient, pharmacy, specialty, and post-acute cost drivers, identifying actionable opportunities to improve medical loss ratio (MLR). </li><li>Partner with Clinical and Pharmacy Operations to shape utilization management initiatives, care management ROI, and targeted interventions for high-cost cohorts. </li><li>Develop advanced risk-stratification and predictive analytics to support proactive care and population health management, and Stars improvement initiatives. </li></ul> <p>Provider Network Financial Strategy</p> <ul> <li>Collaborate with Provider Network leadership to design and evaluate value-based payment models, including shared savings, global capitation, and performance-based incentives. </li><li>Lead financial modeling for provider contracting, rate negotiations, quality incentive programs, and performance guarantees for medical groups, hospitals and ancillary agreements. </li><li>Evaluate network adequacy economics, reimbursement competitiveness, and impact to benefit design. </li></ul> <p>Actuarial, Risk Adjustment & Revenue Optimization</p> <ul> <li>Oversee forecasting, pricing support, revenue models, and CMS bid strategy from a cost-of-care perspective. </li><li>Partner with Risk Adjustment leadership to evaluate RAF gap-closure programs and financial impact. </li><li>Ensure accuracy and integrity of key revenue inputs including risk adjustment, Stars calculations (numerator/denominator support), and CMS payments (including CMS revenue reconciliation). </li></ul> <p>Data, Analytics & Insights</p> <ul> <li>Lead a high-performing analytics organization delivering timely reporting, predictive modeling, trend insights, and executive-level dashboards. </li><li>Drive adoption of advanced analytics, machine learning, and automation to enhance financial and clinical decision-making. </li><li>Partnering with the CIO, ensure the organization has a reliable, integrated data infrastructure supporting real-time business insights. </li></ul> <p>Financial Operations</p> <ul> <li>Monitor and analyze budget variances throughout the year, utilize data for updating forecasts, administer and report on approved budget. </li><li>Analyze and forecast membership, revenue, and medical expense inclusive of MMR database, CMS revenue reconciliation, capitation administration, and risk pool reporting. </li><li>Partner with the VP, Controller in the analysis of appropriate stop loss coverage as well as the opportunity to self-insure. </li><li>Assure accuracy and timeliness of monthly provider group capitation. Oversee related capitation deduct and recovery processes. </li><li>Supervise the monthly risk pool performance reporting and periodic payment and settlement processes. </li><li>Supporting analytic initiatives, refine next generation PMR (Provider Management Report) and financial models to track profitability by medical group, by line of business, by product </li></ul> <p>line, by Plan Benefit Package (PBP), by region, by risk type, and by member type (dual-eligible vs. non-dual eligible).</p> <ul> <li>Prepare monthly Board-level summary and variance explanation (inclusive of rate, volume & utilization) through gross margin by PBP and line item. </li></ul> <p>Leadership & Team Development</p> <ul> <li>Build, mentor, and lead multidisciplinary teams across medical economics, analytics, actuarial partnership, and financial strategy. </li><li>Foster a culture of innovation, accountability, and cross-functional collaboration. </li><li>Represent the organization with external partners, consultants, and regulatory stakeholders. </li></ul> <p>Regulatory Compliance & Governance</p> <ul> <li>Ensure all economic modeling and cost-of-care programs comply with CMS regulations, actuarial standards, and audit requirements. </li><li>Provide executive leadership during CMS audits, financial reviews, and regulatory submissions. </li><li>Other duties as assigned </li></ul> <p>Leadership Expectations</p> <p>By way of leadership approach, mobilize others to create extraordinary results, and unite people to turn challenges into successes by championing the following:</p> <ol> <li>Model the Way: </li></ol> <ul> <li>Clarify values by finding your voice and affirming shared values </li><li>Set the example by aligning actions with shared values </li></ul> <ol start="2"> <li>Inspire a Shared Vision </li></ol> <ul> <li>Envision the future by imagining and sharing exciting possibilities </li><li>Enlist others in a common vision by appealing to shared ambitions </li></ul> <ol start="3"> <li>Challenge the Process </li></ol> <ul> <li>Search for opportunities by seizing the initiative and looking outward for innovative ways to improve </li><li>Experiment and take risks by consistently generating small wins and learning from experience </li></ul> <ol start="4"> <li>Enable Others to Act </li></ol> <ul> <li>Foster collaboration by building trust and facilitating relationships </li><li>Strengthen others by increasing self-determination and developing competence </li></ul> <ol start="5"> <li>Encourage the Heart </li></ol> <ul> <li>Recognize contributions by showing appreciation for individual excellence </li><li>Celebrate the values and victories by creating a spirit of community </li></ul>