Medical Underwriting Subject Matter Expert

nirvanaHealth | RxAdvance; Southborough (MA); On-site; USD 140,000 - 210,000; Full time

Job summary

nirvanaHealth, under RxAdvance Corp., seeks an experienced actuary to build and validate the rating engine for U.S. commercial health insurance. You will specify math, create worked examples in Excel, and ensure the engine matches filings and regulations. This role partners with engineers to translate methodology into scalable platform logic.

The ideal candidate has 5+ years in medical underwriting, pricing for group health, and deep familiarity with ACA small-group rules and rate filings.

Qualifications

• Bachelor’s degree in accounting, mathematics, finance, or similar fields.
• At least 5 years of medical underwriting experience in a health plan or managed care setting.
• 5+ years pricing commercial group health.
• Experience building manual rate models: base claims development, trend, area and demographic factors, industry loads.
• Ability to explain why rating factors affect premiums and how leverage grows with trend.
• Operational ACA small-group knowledge and rate-filing literacy.
• Spreadsheet rigor and auditable worked examples.

Responsibilities

• Reverse-engineer carrier rate filings into precise, implementable factor specifications.
• Build member-level worked examples in Excel with traceable source tables and lookups.
• Own methodology for the manual rating pipeline: base claims, trend, area factors, demographic factors, industry loads, and cost-share waterfall.
• Keep ACA small-group pipeline legally exact: single risk pool, age curves, family build-up, prohibited factors enforced.
• Specify experience rating end to end: credibility formulas, pooling, shock adjustment, completion factors.
• Review engine output against worked examples with the engineering team and resolve discrepancies.
• Translate carriers’ methodologies into platform abstractions and shape pricing for level-funded products.

Skills

Actuarial analysis

Underwriting experience

Excel modeling

Payer industry knowledge

Communication

Education

Bachelor’s degree in accounting, mathematics, finance, or similar fields

Tools

Spreadsheet rigor

Job description

Join us in our mission to transform healthcare! nirvanaHealth (under RxAdvance Corp.) is committed to bringing the art of the possible to the payer and PBM industries. We invest in our employees at every stage of life. Success radiates across all levels of our organization, driven by competitive benefits and a strong focus on employee wellness, we aim to support all aspects of employee growth.

Characterized by curiosity, innovation, and an entrepreneurial mindset, nirvanaHealth is the first to offer medical and pharmacy benefit management solutions that run on the same platform, made possible by our creation, Aria – the first robotic process automation cloud platform designed for healthcare.

Under the leadership of our Chairman John Sculley, former Apple CEO, and our President & CEO Ravi Ika, nirvanaHealth endeavors to sizably reduce the $1 trillion in waste in healthcare administrative and medical costs. We are seeking self-determined players to join our team – folks who embrace the grind and hustle of a growing company, are collaborative and innovative, are life-long learners and growers, and have an entrepreneurial and positive mindset.

Job Summary:

nirvanaHealth is building a multi-tenant rating and quote-to-installation platform for U.S. commercial health insurance — Small Group and Large Group, Fully-Insured through Level-Funded and Self-Funded. Any carrier's filed methodology loads as configuration, never code: their rate tables, their pipeline recipe, their credibility formulas, their networks. A national carrier is our first design partner, and their filed large-group methodology (a 44-table manual rating pipeline plus credibility-blended experience rating) is the engine's first calibration.

The rating engine is the pricing brain of that platform. It takes a group, its census, a plan design, and a funding type, and returns per-member, per-tier, and composite rates with a factor-by-factor explainability waterfall. Getting those numbers provably right —against filings, against regulation, against an underwriter's scrutiny — is what this role exists to do.

You are the calculations authority: the credentialed actuary who specifies the math, builds the worked examples, and validates that the engine reproduces them exactly. Engineers implement to your spec and test against your numbers. When the engine and your spreadsheet disagree, you adjudicate — to the penny.

This is not a production-coding role. It is a methodology, specification, and validation role for someone who finds deep satisfaction in a rate build-up that ties out. Coding skills are a plus.

Job Responsibilities (but not limited to):

• Reverse-engineer carrier rate filings — actuarial memoranda, SERFF exhibits, rate templates — into precise, implementable factor specifications.
• Build member-level worked examples in Excel, every factor traced to its source table and lookup keys. These become the engine's regression fixtures.
• Own methodology for the manual rating pipeline: base claims, trend, area factors, demographic factors, industry loads, and the multi-step cost-share (CPD) waterfall for deductibles, copays, coinsurance, and OOP maximums.
• Keep the ACA small-group pipeline legally exact: single risk pool and index rates, federal and state age curves, family build-up, and hard enforcement of prohibited rating factors.
• Specify experience rating end to end: credibility formulas, pooling points, shock-claim adjustment, IBNR completion, and trend to the policy period.
• Review engine output against your worked examples with the engineering team and resolve every discrepancy.
• As the platform scales: translate additional carriers' filed methodologies into the same platform abstractions, and shape stop-loss and LASER pricing for level-funded products.

Education and/or Training:

• Bachelor’s degree accounting, mathematics, finance, or similar fields required.

Professional Experience:

• At least 5 years of total experience with medical underwriting in a health plan, managed care setting. 5+ years pricing commercial group health.
• Experience building manual rate models: base claims development, trend, area and demographic factors, industry loads.
• Benefit-relativity depth. Continuance tables, deductible and OOP leverage, copay/coinsurance relativities — you can explain why a $500 deductible increase moves premium roughly 4%, and why that leverage grows with trend.
• Operational ACA small-group knowledge: 45 CFR § 147.102 factors, single risk pool mechanics, state age-curve and tobacco variations, and what is prohibited.
• Experience-rating fluency: credibility theory, pooling, shock adjustment, completion factors.
• Rate-filing literacy. Handed an unfamiliar carrier's fi ling, you can reverse the methodology unassisted.
• Spreadsheet rigor and a documentation habit. Your worked examples are auditable artifacts, not scratch work.
• Comfortable working with engineers — reading pseudocode, reviewing output diffs, and explaining actuarial intent in implementable terms.