Claims & Provider Relations Oversight Specialist

Western Health Advantage•Sacramento, CA

1d•$70,304 - $85,000•Hybrid

About The Position

Western Health Advantage is seeking a detail-oriented Claims & Provider Relations Oversight Specialist to support compliance and regulatory operations within its Claims and Provider Relations department. The role ensures departmental compliance with federal and state regulations, accreditation standards, and internal policies, and serves as a resource for audits, regulatory filings, reporting, and compliance initiatives. The ideal candidate is organized, analytical, and collaborative, with experience in California managed care, claims and provider operations, and healthcare compliance.

Requirements

Bachelor's degree in Compliance, Healthcare Administration, Legal or Regulatory Affairs, or a related field.
Three years of experience in healthcare compliance, governance, auditing, quality, accreditation, or regulatory operations.
Two years of experience with a California-based HMO in Claims and/or Provider Relations.
One year of experience implementing compliance programs involving NCQA, Knox-Keene, HIPAA, Covered California, PCI, or similar regulatory requirements.
Strong analytical, organizational, and communication skills.
Intermediate proficiency with Microsoft Office applications.
Ability to manage multiple priorities while working independently and collaboratively.

Nice To Haves

Experience with SmartSheet, SCAN/Cognos, or similar reporting tools.
Strong knowledge of healthcare regulatory and accreditation requirements.
Excellent project coordination and organizational skills.
Experience interpreting regulatory guidance and implementing compliance initiatives.
Ability to analyze data, identify compliance risks, and recommend solutions.
Strong written and verbal communication skills and ability to collaborate across departments and with external partners.

Responsibilities

Coordinate compliance projects, regulatory filings, audits, and corrective action plans.
Develop, maintain, and update departmental policies and procedures.
Monitor compliance with federal and state regulations, NCQA standards, Knox-Keene requirements, HIPAA, and other applicable regulations.
Review regulatory guidance, legislation, and compliance communications, and provide recommendations and responses as needed.
Support Annual Network Review (ANR), Geo Access, Provider Appointment Availability Surveys (PAAS), Provider Satisfaction Surveys (PSS), after-hours surveys, and related compliance activities.
Prepare compliance communications, provider education materials, newsletters, and handbook updates.
Monitor, audit, and report on department performance and compliance metrics.
Provide compliance education and training to department staff.
Oversee external vendors and medical groups to ensure timely and accurate claims processing and provider data maintenance.
Track corrective actions and analyze compliance trends to identify opportunities for improvement.
Maintain organized compliance documentation and regulatory records.