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Company

Original Job Post

Wellfleet · 3 days 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.

Set direction and manage the efforts of the Claims Compliance Team.

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.

Conduct hiring, employee performance reviews, promotions, retention and termination activities.

Coach and encourage others to take ownership of their development.

Manage all aspects of compliance 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.

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

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Healthcare regulatory complianceProject managementRisk assessmentQuality assuranceInsurance claims handlingMedical terminologyICD10CPT codesCompliance activitiesLegal interpretationRoot cause analysisDeadline managementMicrosoft Office proficiencyProblem-solvingAnalyticalOrganizationalInterpersonal communicationAdaptabilityEthicsCollaboration

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.