Claims Compliance Manager, TPA

Heathos LLC • Alpharetta, GA

4d

About The Position

THE CLAIMS COMPLIANCE MANAGER IS A FUNCTIONAL COMPLIANCE MANAGER RESPONSIBLE FOR OVERSIGHT OF REGULATORY AND OPERATIONAL COMPLIANCE WITHIN A HEALTH CLAIMS THIRD-PARTY ADMINISTRATOR (TPA) ENVIRONMENT.

THIS ROLE PARTNERS DIRECTLY WITH CLAIMS OPERATIONS, NETWORK REPRICING, VENDOR MANAGEMENT, AND LEADERSHIP TO ENSURE THAT CLAIMS ADMINISTRATION ACTIVITIES, INCLUDING REPRICING, ADJUDICATION, EOB ISSUANCE, VENDOR COORDINATION, AND REGULATORY REPORTING, ARE CONDUCTED IN COMPLIANCE WITH APPLICABLE STATE TPA LAWS, HIPAA, ERISA (AS APPLICABLE), AND CONTRACTUAL OBLIGATIONS.

THE IDEAL CANDIDATE HAS PRIOR CLAIMS TPA EXPERIENCE AND UNDERSTANDS THE OPERATIONAL REALITIES OF CLAIMS INTAKE AND PROCESSING, INCLUDING BUT NOT LIMITED TO, 837/835 WORKFLOWS, FEE SCHEDULE APPLICATION, REPRICING METHODOLOGIES, EOB PRODUCTION, AND DELEGATED VENDOR OVERSIGHT.

THIS IS A FUNCTIONAL LEADERSHIP ROLE (NOT A PEOPLE-MANAGER POSITION INITIALLY), RESPONSIBLE FOR BUILDING CONTROLS, DOCUMENTING PROCESSES, AND PROACTIVELY IDENTIFYING RISK.

Requirements

• 5+ YEARS OF EXPERIENCE IN A HEALTH CLAIMS TPA ENVIRONMENT
• DIRECT EXPERIENCE WITH CLAIMS PROCESSING WORKFLOWS
• WORKING KNOWLEDGE OF:
• STATE TPA REGULATORY FRAMEWORKS
• CLAIMS ADJUDICATION AND REPRICING
• HIPAA PRIVACY & SECURITY RULES
• ERISA FUNDAMENTALS
• EXPERIENCE RESPONDING TO REGULATORY INQUIRIES OR AUDITS PREFERRED
• ABILITY TO TRANSLATE OPERATIONAL PROCESSES INTO DOCUMENTED CONTROLS

Responsibilities

• Regulatory Oversight- Claims Activities
• Monitor compliance with state TPA statutes and regulations applicable to health claims administration
• Evaluate whether operational activities constitute claims adjudication, adjustment, or repricing under applicable law
• Support state licensing inquiries and DOI responses related to claims operations
• Maintain regulatory inventory specific to claims handling requirements
• Claims Process Control and Risk Review
• Review and ensure end-to-end claims workflows are accurately documented
• Identify compliance risk in:
• Multiplier or fee schedule applications
• Claims communications to members/providers
• Ensure EOB language and format meet regulatory requirements
• Validate adherence to contractual authority limitations
• Audit and Monitoring Program Development
• Build and execute a claims specific compliance monitoring program
• Track corrective action items and remediation timelines
• Develop audit tools for:
• Sample claim file reviews
• Repricing validation
• Timeliness standards

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed