Senior Manager, Medical Loss Ratio

Role Overview

• Accountable for the Medical Loss Ratio (MLR) compliance and reporting program across assigned lines of business
• 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

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
• 6+ years people leadership experience (direct or matrix), including responsibility for setting priorities, assigning work, coaching/developing talent, and ensuring timely delivery of complex work products 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

Benefits

• health insurance
• 401K and stock purchase plans
• tuition reimbursement
• paid time off plus holidays
• flexible approach to work with remote, hybrid, field or office work schedules