Regulatory Operations Analyst III

Fidelis Care - New Jersey; Georgia; Hybrid; USD 70,000 - 126,000; Full time

Benefits offered by this job

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Remote, hybrid, field or office work S

Job summary

Centene is seeking a regulatory policy expert to review and summarize legislation impacting commercial products at the federal and state levels. The role supports compliance readiness, regulatory reporting, and formal approvals for Marketplaces and commercial offerings.

You will coordinate with Compliance, SIU, Payment Integrity, Claims Operations and Legal to address regulatory risks, draft regulator responses, and lead large regulatory projects with cross-functional teams.

Qualifications

• Bachelor's degree required; master’s or JD may supplement experience
• 4+ years experience in health insurance, legal, compliance or related field
• Experience interpreting regulations and communicating to varied audiences
• Experience in Medicaid managed care or related healthcare operations preferred
• Experience with SIU, Compliance, FWA, Payment Integrity or related teams strongly preferred
• Experience supporting regulatory audits, investigations, or regulator-facing responses preferred
• Proficiency with Excel and BI tools (Power BI, SQL, SAS) preferred

Responsibilities

• Identify, analyze and interpret proposed or enacted legislation at federal/state level
• Perform risk assessments impacting business applications, claims operations and payment integrity
• Maintain regulatory reference databases and exhibits
• Draft responses for external information requests for regulatory filings
• Collaborate with Legal, Compliance, SIU, Payment Integrity, and Finance on regulatory issues
• Lead large cross-functional regulatory projects and present findings clearly

Skills

Excel

Power BI

SQL

SAS

Education

Bachelor's Degree in Business, Communications, Healthcare, Political Science/Pre-Law or equivalent

Master's Degree in a related field / JD may be considered in place of experience

Tools

Power BI

SQL

SAS

Job description

You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

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.

Position Purpose

Reviews, interprets and summarizes proposed and enacted legislation and regulatory updates to the business as a subject matter expert on various complex topics. Performs state or federal policy research, regulatory reporting, and regulatory change monitoring with a goal of supporting compliance, regulatory readiness, and formal regulatory approval of commercial and Marketplace products.

• 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.

Education/Experience

• Bachelor's Degree in Business, Communications, Healthcare, Political Science/Pre-Law or equivalent experience required. Master's Degree in a related field, Juris Doctorate degree may be considered in place of experience preferred.
• 4+ years experience in health insurance, legal, compliance or related field required.
• 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.

By applying to this requisition, you acknowledge and understand that you may be considered for other job opportunities for which Centene believes you may be qualified.

Pay Range: $70,100.00 - $126,200.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act