Regulatory Operations Analyst III

This is a fully remote position, open to applicants in Florida, +3 more states.

📋 Description

• Analyze, interpret, and summarize both proposed and enacted legislation and regulatory updates as a subject matter expert.

• Conduct research on state and federal policies, regulatory reporting, and monitor changes in regulations.

• Assist in ensuring compliance, regulatory readiness, and obtain formal regulatory approval for Commercial and Marketplace products.

• Identify, examine, and interpret legislation pertinent to Centene’s commercial products and communicate findings to relevant departments.

• Independently carry out risk assessments that encompass business applications, claims operations, payment integrity processes, and downstream outputs.

• Maintain databases, reports, exhibits, and reference materials for legislative, regulatory, compliance, audit, and inquiry activities.

• Execute complex regulatory analyses and share key updates on Commercial/ACA regulations.

• Lead the interpretation of regulations and clarify Commercial/ACA rules to diverse audiences.

• Provide guidance regarding emerging regulations, regulatory inquiries, audits, oversight of fraud, waste, and abuse, as well as payment integrity matters.

• Coordinate regulatory inquiries, reporting obligations, exhibits, audits, and requests from agencies.

• Collaborate with Compliance, SIU, Payment Integrity, Claims Operations, Finance, Legal, and other cross-functional teams.

• Identify regulatory risks, assist in investigations, and analyze operational trends.

• Develop strategies and draft responses to legal, contractual, regulatory, filing, and policy issues.

• Represent the department in cross-departmental meetings and escalate issues to management.

• Comprehend regulations and business needs across various states and federal commercial health insurance regulations.

• Evaluate objections related to regulatory interpretation and lead responses directed to regulators.

⛳️ Requirements

• Bachelor’s Degree in Business, Communications, Healthcare, Political Science/Pre-Law, or equivalent experience is required.

• A minimum of 4 years of experience in health insurance, legal compliance, or a related field is required.

• Preferred experience in reviewing regulations and delivering audience-appropriate interpretations.

• Preferred background in commercial health insurance, Medicaid managed care, claims operations, compliance, payment integrity, or similar healthcare operations.

• Strongly preferred experience collaborating with SIU, Compliance, 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 activities, provider utilization patterns, or operational risk indicators.

• Strongly preferred experience in supporting regulatory audits, investigations, agency inquiries, corrective action plans, or responses directed at regulators.

• Proficiency in Excel and experience with reporting, analytics, or business intelligence tools such as Power BI, SQL, SAS, or similar platforms is strongly preferred.

• Strongly preferred experience in Medicaid managed care, including MFD, MFCU, payment integrity, TPL, or recovery activities.

• Must be authorized to work in the U.S. without requiring employment-based visa sponsorship now or in the future.

🏝️ Benefits

• Competitive pay

• Health insurance

• 401K plan

• Stock purchase plans

• Tuition reimbursement

• Paid time off

• Holidays

• Flexible approach to work with remote, hybrid, field, or office work schedules

• Additional forms of incentives may be included in total compensation