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Claims Compliance Analyst

2 months ago

East Longmeadow, United States The MH Group LLC Full time
Job DescriptionJob DescriptionDescription:

The Claims Compliance Analyst occupies an essential role, necessitating a thorough knowledge of policies and procedures, a profound expertise in the claims process, and the ability to process claims effectively. The ideal candidate will lead the establishment, oversight, and enactment of compliance-centered activities within the claims department. This role requires detailed coordination with the compliance team to evaluate risks and controls and to flawlessly implement and communicate any new regulations affecting the claims team.


Core Responsibilities Include:

  • Cultivate a complete understanding of the claim adjudication process, including:
    • Processing claims promptly and precisely as per plan documents.
    • Performing in-depth analyses of medical treatments submitted for reimbursement.
    • Administering and enforcing coverage terms as outlined in policies.
  • Maintain and update expert knowledge on state/federal insurance regulations and mandates.
  • Keep current with product/system developments, serving as a specialist in the field.
  • Independently solve challenges with minimal oversight.
  • Collaborate with compliance and legal teams, using the RegEd system to understand and apply both new and existing regulations.
  • Design, manage, and review compliance tasks connected to claims such as risk assessments, monitoring of crucial regulations, policies & procedures, support in exam preparations, problem reporting and escalation, and the execution of training programs and corrective measures.
  • Oversee and enforce claim-related compliance policies and procedures.
  • Employ RegEd to manage assigned tasks and integrate new laws, rules, and regulations.
  • Help in examining claim-related tasks for market conduct assessments.
  • Develop instructional tools for regulatory issues affecting claims that necessitate special handling.
  • Engage regularly in compliance meetings.
  • Verify the accuracy of claim-related compliance reports.
  • Analyze quick payment reports to confirm correct claim dates and properly calculate penalties/interest.
  • Adjust claims in line with regulatory necessities.
  • Communicate potential issues or concerns to the management.
  • Undertake additional responsibilities as circumstances or assignments demand.

Candidate Requirements:

  • At least 5 years of experience in healthcare claim processing.
  • Robust grasp of policies and procedures.
  • Adept at designing, conducting, and evaluating compliance self-monitoring activities.
  • Skilled in interpreting legal department-directed laws/regulations.
  • Capable of effectively assessing, prioritizing, and conveying risks within claim operations.
  • Strong organizational prowess and exceptional attention to detail.
  • Superb written and verbal communication skills, enhanced by strong presentation and interpersonal skills.
  • Capable of flourishing in a fast-paced setting, making swift decisions, meeting tight deadlines, and adapting to a variety of scenarios.
  • Proficient in analyzing complex problems, pinpointing root causes, and maintaining focus in a dynamic environment.
  • Able to juggle multiple tasks simultaneously.
  • Exhibits a strong work ethic and advanced analytical abilities, efficiently identifying and resolving potential challenges.
  • Effective in working independently and as part of a team, as well as in engaging with colleagues and business units at all levels of the organization.
Requirements: