Note: The job is a remote job and is open to candidates in USA. Centene is a diversified national healthcare organization focused on transforming the health of its communities and serving its members. The Regulatory Operations Analyst III reviews, interprets, and summarizes legislation and regulatory updates, conducts policy research and risk assessments, and supports regulatory compliance and approval of commercial and Marketplace products. The role also coordinates regulatory inquiries, audits, filings, and cross-functional responses involving commercial health insurance operations.
Responsibilities
- Identifies, analyzes and interprets proposed or enacted legislation related to Centene's commercial product at the federal and state level and communicates findings to impacted departments
- Independently performs risk assessments, including impact to business applications, claims operations, payment integrity processes, and downstream output
- Maintains databases, reports, exhibits, and other reference materials related to legislative, regulatory, compliance, audit, and inquiry activities
- Performs comprehensive, complex regulatory analyzes, including the review, summarization and dissemination of key regulatory updates and changes related to Commercial/ACA rules and regulations at the state and/or federal level
- Leads regulatory interpretation related to Commercial/ACA Rules and regulations and the commercial product explaining concepts clearly and adapting language and presentation based on audience level
- Provides guidance to business partners regarding emerging regulations, regulatory inquiries, audit activity, fraud, waste and abuse (FWA) oversight, and payment integrity matters
- Coordinates regulatory inquiries, reporting requirements, exhibits, audits, and requests from state and federal agencies, maintaining accurate and timely responses in partnership with operational stakeholders
- Partners with Compliance, Special Investigations Unit (SIU), Payment Integrity, Claims Operations, Finance, and other cross-functional teams to identify regulatory risks, support investigations, and analyze operational trends
- Uses persuasive arguments and secures cooperation from the business in order to address potential legal, contractual and/or regulatory issues
- Ability to determine appropriate approach for solving regulatory problems
- Develops trust-based relationships within varied audiences and collaborates with other functional areas to lead large projects and initiatives
- Attends cross-departmental meetings as department representative, provides guidance to the business related to commercial regulatory requirements and appropriately escalates matters to management
- Develops solutions to address potential legal, contractual and regulatory issues while working closely with Legal, Compliance, Payment Integrity, and other operational stakeholders
- Independently drafts responses to external requests for information required by the organization for its regulatory filings and/or for policy needs
- Responsibility for understanding regulations and business needs for multiple states, as well as federal regulations pertaining to the commercial health insurance market
- Assesses and analyzes objections related to regulatory interpretation and leads drafting of appropriate responses which are provided to regulators related to commercial/ACA filings
Skills
- Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT
- Ability to determine appropriate approach for solving regulatory problems
- Bachelor's Degree in Business, Communications, Healthcare, Political Science/Pre-Law or equivalent experience required
- 4+ years experience in health insurance, legal, compliance or related field required
- Master's Degree in a related field, Juris Doctorate degree may be considered in place of experience preferred
- Experience reviewing regulations and providing interpretation using terms appropriate for the audience preferred
- Experience in commercial health insurance, Medicaid managed care, claims operations, compliance, payment integrity, or related healthcare operations preferred
- Experience partnering with Special Investigations Unit (SIU), Compliance, Fraud, Waste and Abuse (FWA), Payment Integrity, or related operational teams strongly preferred
- Experience supporting claims operations, including medical claims processing, provider billing practices, payment accuracy, reimbursement workflows, or claims-related regulatory activities strongly preferred
- Experience analyzing claims data, billing trends, overpayment activity, provider utilization patterns, or operational risk indicators strongly preferred
- Experience supporting regulatory audits, investigations, agency inquiries, corrective action plans, or regulator-facing responses strongly preferred
- Proficiency with Excel and experience using reporting, analytics, or business intelligence tools such as Power BI, SQL, SAS, or similar platforms strongly preferred
- Experience within Medicaid managed care, including exposure to Medicaid Fraud Division (MFD), Medicaid Fraud Control Unit (MFCU), payment integrity, third-party liability (TPL), or recovery activities strongly preferred
Benefits
- Health insurance
- 401K plan
- Stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- Flexible approach to work with remote, hybrid, field or office work schedules
Company Overview