Senior Manager, Medical Loss Ratio

This is a fully remote position, open to applicants in Missouri.

📋 Description

• Responsible for the Medical Loss Ratio (MLR) compliance and reporting program across designated lines of business, ensuring precise calculations, robust governance and controls, and timely submission of federal and state filings.

• Offers strategic and operational leadership for comprehensive MLR activities, involving methodology oversight, documentation standards, audit readiness, rebate execution, and regulatory examinations.

• Leads and mentors a team, establishes priorities and deliverables, and fosters cross-functional alignment with Finance, Actuarial, Legal/Compliance, Government Affairs, and operational partners.

• Acts as the escalation point for complex interpretation and judgment issues, proactively identifies and mitigates enterprise risks, and champions continuous improvement initiatives that enhance data quality, consistency, and regulatory confidence.

• Oversees the MLR reporting calendar and delivery model for assigned lines of business; sets expectations, assigns tasks, and ensures that filings to CMS and state regulators are accurate, complete, and submitted punctually.

• Provides oversight and final review of MLR methodology, assumptions, and classifications; ensures consistent application of federal and state requirements (e.g., ACA commercial markets, Medicare Advantage, Medicaid) and alignment with internal policies.

• Facilitates cross-functional forums and working sessions with Finance, Actuarial, Legal/Compliance, Government Affairs, and operations to drive decision-making, resolve issues, and ensure clear ownership of actions impacting MLR results and regulatory posture.

• Designs, implements, and maintains MLR governance, internal controls, and documentation standards; approves key artifacts and ensures an audit-ready trail from data sources to final filing outputs.

• Oversees MLR performance monitoring and threshold management; interprets drivers, assesses emerging risks, and sponsors mitigation strategies and corrective action plans in collaboration with business owners.

• Manages 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; supervises detailed analyses, internal audits, and control testing; ensures remediation is implemented, validated, and sustained.

• Stays informed of legislative and regulatory changes affecting MLR; evaluates impacts, advises leadership on options and risks, and leads the implementation of necessary policy, process, and control updates.

• Maintains oversight of MLR-related policies, procedures, and tools (or their enterprise alignment); sets standards for accurate claims classification, quality improvement initiatives, and administrative expenses, and resolves interpretation disputes.

• Serves as the primary accountable leader for regulatory inquiries, audits, and examinations related to MLR; approves responses, ensures the quality of supporting documentation, and coordinates cross-functional participation.

• Mentors and develops team members; offers 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 regarding MLR compliance status, key risks, control effectiveness, and remediation progress.

• Contributes to process improvement and data governance initiatives (e.g., standardization, automation, reconciliations, evidence retention) to enhance oversight, efficiency, and consistency throughout the MLR lifecycle.

• Performs additional duties as assigned. Adheres to all policies and standards.

⛳️ Requirements

• 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 of experience in healthcare finance, managed care operations, or a related field required.

• Experience in interpreting and applying federal and state MLR guidance, including utilizing judgment to resolve complex classification and methodology questions and translating requirements into scalable processes and controls required.

• Experience providing oversight and final review of intricate analyses (e.g., reconciliations, variance/root-cause analysis) and ensuring documentation quality suitable for audits and regulatory submissions required.

• Proven experience in communicating with and influencing senior leaders and cross-functional stakeholders, including escalating risks/issues and presenting clear recommendations and decision points required.

• Advanced proficiency with Excel and reporting/analytics tools required.

• Experience with health plan finance/claims systems and data warehouses preferred.

🏝️ Benefits

• Competitive compensation.

• Health insurance.

• 401K and stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

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