Senior Manager, Medical Loss Ratio

🕒 6 dias atrás

🏰 Missouri – Remoto

🏰 Missouri – Remote

💵 $107.700 - $199.300 / ano

⏰ Tempo Integral

🟠 Sênior

👔 Gerente

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Centene Corporation

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1984

⚕️ Seguro de Saúde

🤝 Sem Fins Lucrativos

🌍 Impacto Social

Healthcare Insurance • Non-profit • Social Impact

Centene Corporation é uma provedora líder de serviços de saúde patrocinados pelo governo, especializada em oferecer soluções de saúde acessíveis e de alta qualidade. Há mais de 40 anos, a Centene tem se dedicado a transformar a saúde das comunidades, ampliando o acesso a Medicaid, Medicare e ao Health Insurance Marketplace, além de atender comunidades militares por meio do programa TRICARE. Como a maior organização de managed care do Medicaid e participante-chave no Marketplace, a Centene enfatiza a entrega de cuidados de saúde com foco local, combinada a parcerias sólidas com organizações sem fins lucrativos para atender às necessidades únicas de seus membros. A Centene também é comprometida com sustentabilidade corporativa e responsabilidade social, priorizando a gestão ambiental e a governança ética para promover o bem-estar das comunidades que atende.

Descrição

• Accountable for the Medical Loss Ratio (MLR) compliance and reporting program across assigned lines of business, ensuring accurate calculation, strong governance and controls, and timely submission of federal and state filings. • Provides strategic and operational leadership for end-to-end MLR activities, including methodology oversight, documentation standards, audit readiness, rebate execution, and regulatory examinations. • Leads and develops a team, sets priorities and deliverables, and drives cross-functional alignment with Finance, Actuarial, Legal/Compliance, Government Affairs, and operational partners. • Serves as the escalation point for complex interpretation and judgment matters, proactively identifies and mitigates enterprise risk, and sponsors continuous improvement initiatives that strengthen data quality, consistency, and regulatory confidence. • Provides oversight of the MLR reporting calendar and delivery model for assigned lines of business; set expectations, assign work, and ensure filings to CMS and state regulators are accurate, complete, and submitted on time. • Provides oversight and final review of MLR methodology, assumptions, and classifications; ensure consistent application of federal and state requirements (e.g., ACA commercial markets, Medicare Advantage, Medicaid) and alignment with internal policy. • Leads cross-functional forums and working sessions with Finance, Actuarial, Legal/Compliance, Government Affairs, and operations to drive decisions, resolve issues, and ensure clear ownership of actions that impact MLR results and regulatory posture. • Designs, implements, and maintains MLR governance, internal controls, and documentation standards; approve key artifacts and ensure an audit-ready trail from data sources through final filing outputs. • Oversees MLR performance monitoring and threshold management; interprets drivers, evaluates emerging risk, and sponsors mitigation strategies and corrective action plans in partnership with business owners. • Has oversight of MLR rebate planning and execution, including governance over inputs, leadership approvals, and downstream communications to ensure compliance with federal and state requirements and timelines. • Establishes a risk-based monitoring and review plan; oversees deeper-dive analyses, internal audits, and control testing; ensures remediation is implemented, validated, and sustained. • Maintains awareness of legislative and regulatory changes impacting MLR; assess impact, advise leadership on options and risk, and lead implementation of required policy, process, and control updates. • Maintains oversight of MLR-related policies, procedures, and tools (or their enterprise alignment); set standards for accurate classification of claims, quality improvement activities, and administrative expenses, and resolve interpretation disputes. • Serves as the primary accountable leader for regulatory inquiries, audits, and examinations related to MLR; approve responses, ensure supporting documentation quality, and coordinate cross-functional participation. • Coaches and develops team members; provides consultation and training to stakeholders on MLR requirements, controls, and risk management expectations. • Provides executive-ready reporting and recommendations to senior leadership and governance committees on MLR compliance status, key risks, control effectiveness, and remediation progress. • Contributes process improvement and data governance initiatives (e.g., standardization, automation, reconciliations, evidence retention) to improve oversight, efficiency, and consistency across the MLR lifecycle. • Performs other duties as assigned. Complies with all policies and standards.

🎯 Requisitos

• Bachelor's Degree in Finance, Accounting, Actuarial Science, Business, Healthcare Administration, Public Health, or a related field; or equivalent experience required • Juris Doctor (JD) preferred • Master's Degree preferred • 4+ years healthcare finance, managed care operations or related experience required • Experience interpreting and applying federal and state MLR guidance, including use of judgment to resolve complex classification and methodology questions and translate requirements into scalable processes and controls required • Experience providing oversight and final review of complex analyses (e.g., reconciliations, variance/root-cause analysis) and ensuring documentation quality appropriate for audits and regulatory submissions required • Experience communicating with and influencing senior leaders and cross-functional stakeholders, including escalating risks/issues and presenting clear recommendations and decision points required • Advanced experience with Excel and reporting/analytics tools required • Experience with health plan finance/claims systems and data warehouses preferred

🏖️ Benefícios

• competitive pay • health insurance • 401K and stock purchase plans • tuition reimbursement • paid time off plus holidays • flexible approach to work with remote, hybrid, field or office work schedules