200+ applicants

Company

Wellfleet · 1 day ago

Claims Business Compliance Manager

United States

Full-time

Remote

Mid Level

$80K/yr - $100K/yr

4+ years exp

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Employee BenefitsHealth Care

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Responsibilities

Collaborate with Legal and Compliance to implement new and/or existing regulations utilizing regulatory system.

Stay current with benefits and regulations affecting claims handling.

Maintain a detailed understanding of State/Federal insurance regulations and mandates.

Develop and implement compliance policies, initiatives and procedures that align with relevant laws, regulations, and industry standards, ensuring these updated policies are effectively communicated throughout Claim Operations.

Set direction and manage the efforts of the Claims Compliance Team to ensure validity, accuracy, and timeliness of compliance initiatives in accordance with plan documents, policies, procedures, and state and federal regulations.

Conduct internal audits to ensure adherence to regulations and standards.

Perform risk analysis, determine root cause, and recommend corrective action.

Collaborate with claim operations by providing detailed analysis of trends and insights to ensure continuous process improvement.

Conduct hiring, employee performance reviews, promotions, retention and termination activities in consultation with Management and HR.

Coach and encourage others to take ownership of their development.

Manage all aspects of compliance; including but not limited to planning, control evaluation, testing methodologies, reporting, and issue follow-up.

Identify continuous process improvement opportunities resulting in compliant claim handling.

Develop and cultivate collaborative relationships with all levels of management.

Develop, execute, and audit Claim related compliance items (e.g. risk assessment, testing & monitoring of key regulations, policies & procedures, assist with exam preparation, issue reporting and escalation, training program, corrective actions).

Participate in recurring compliance meetings.

Manage escalated issues and/or problems.

Manage gathering claim documentation for market conduct exams.

Adherence to internal key performance metrics.

Identify Operating Plan goals that are beneficial to the company and ensure deliverables are met.

Perform other duties as assigned.

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Healthcare regulatory complianceRisk assessmentInsurance claims handlingMedical terminologyQuality assurance standardsProject managementICD10 codesCPT codesMicrosoft Office suite

Required

Bachelor's degree in healthcare administration or related field and 3+ years of relevant work experience or equivalent combination of education and experience.

4+ years of health care regulatory compliance leadership or related experience.

2+ years of project management experience.

Strong understanding and ability to interpret healthcare laws and regulations.

Solid risk assessment capabilities.

Strong understanding of quality assurance standards, plan development, change control, and documentation.

Strong insurance claims handling and administration experience.

Medical terminology proficiency, including basic knowledge of ICD10 and CPT codes.

Ability to design, conduct and report on compliance activities.

Ability to digest and understand laws/regulations as interpreted by Legal Department.

Ability to assess, prioritize and communicate risk within Claim Operations.

Strong analytical, organizational, and problem-solving abilities to identify root cause and address issues effectively.

Excellent written, verbal, presentation, and interpersonal communication skills.