Claims Business Compliance Manager

November 5

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The MH Group (ManeHire)

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Description

• The ideal candidate for this role is tasked with assessing and refining the claims operation's processes and protocols, ensuring strict adherence to internal, state, and federal regulations. • The role entails conducting both regular and targeted audits to ensure compliance with company standards and best practices within the accident & health and voluntary benefits sectors. • Beyond compliance, the role involves mentoring team members, identifying educational needs, fostering professional development, and handling queries to enhance staff capabilities. • Moreover, the candidate will be responsible for ensuring that all project and departmental targets are achieved within the allocated budgets. • Key Responsibilities: Collaborate with legal and compliance teams to effectively implement and manage both new and existing regulations using systematic approaches. • Keep abreast of ongoing changes in benefits and claims handling regulatory environments. • Gain and maintain a comprehensive understanding of relevant insurance regulations at both state and federal levels. • Formulate and implement compliance policies, initiatives, and procedures that align with applicable laws and industry norms, ensuring they are well communicated across all operations. • Oversee the claims compliance team to maintain accuracy, legitimacy, and timeliness of compliance measures based on regulatory documents, policies, and procedures. • Execute internal audits to consistently meet regulatory standards. • Conduct risk assessments, identify the fundamental issues, and implement corrective measures. • Provide in-depth operational analysis to promote continuous improvement and enhanced efficacy within claim operations. • Manage recruitment processes, performance assessments, career progression, retention strategies, and termination procedures in partnership with HR and higher management. • Encourage personnel to take proactive steps in their professional development. • Handle full spectrum of compliance activities, including planning, evaluating controls, testing methodologies, compiling reports, and following up on issues. • Discover and implement strategies for continual process improvements that ensure compliant operations. • Build and maintain productive relationships across all management levels to facilitate a collaborative approach to compliance. • Develop, orchestrate, and review compliance activities such as risk assessments, essential regulatory tests, and procedure monitoring; assist with examinations, issue reporting, resolving escalations, training, and corrective measures. • Regularly engage in compliance meetings and manage complex issues and dilemmas. • Oversight of the collection of documents for regulatory examinations. • Adhere to established performance metrics. • Set and achieve strategic objectives that align with company goals, ensuring successful outcomes. • Undertake additional responsibilities as required.

Requirements

• A Bachelor’s degree in Healthcare Administration or a related field, supplemented by at least 3 years’ relevant experience or an equivalent blend of education and experience. • At least four years of demonstrated leadership in healthcare regulatory compliance or a related area. • A minimum of 2 years experience in project management. • Profound understanding and interpretation skills concerning healthcare regulations. • Robust capability in risk assessment and quality assurance practices. • Extensive experience in insurance claims management and administration. • Well-versed in medical terminology with knowledge of ICD10 and CPT codes. • Skilled in designing, conducting, and documenting compliance-related activities. • Capacity to understand and interpret laws and regulations as laid out by legal teams. • Effective at assessing, prioritizing, and communicating operational risks. • Strong analytical skills to identify and resolve issues efficiently. • Excellent communication and interpersonal skills, with an ability to present information clearly and persuasively. • Able to handle a fast-paced environment, managing multiple tasks simultaneously to meet deadlines. • Demonstrates integrity and a solid commitment to ethical practices and compliance. • Proficient in working collaboratively within all levels of an organization. • Competent in Microsoft Office Suite.