Claims Compliance Manager, TPA
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
- Working knowledge of claims adjudication and repricing
- Working knowledge of HIPAA privacy & security rules
- Working knowledge of ERISA fundamentals
- Ability to translate operational processes into documented controls
Nice To Haves
- Experience responding to regulatory inquiries or audits preferred
Responsibilities
- 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
- 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
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
