Remote Fraud Risk Management Jobs in Columbia, MO

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.

Applicants for this job have the flexibility to work remote from home anywhere in the Continental United States.

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:
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.

Education/Experience:

• 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

Licenses/Certifications:

• CPA, CMA, CIA, or other relevant accounting/audit credential preferred
• CHC, CRC or other healthcare compliance certification preferred

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