Senior Claims Compliance Specialist

4 weeks ago

Springfield, Massachusetts, United States The MH Group Full time
Job Summary

The MH Group is seeking a highly skilled Senior Claims Compliance Specialist to lead our Claims Compliance & Quality Assurance team. This is a critical role that requires a deep understanding of state and federal regulations and industry best practices for accident & health and voluntary benefits.

The ideal candidate will have a strong background in healthcare regulatory compliance, with a proven track record of ensuring compliance with plan documents, state and federal regulations, and guidelines. They will be responsible for reviewing processes and practices for continuous improvement, tracking claim quality reports, and developing compliance and quality assurance policies and procedures.

The successful candidate will also have excellent leadership and communication skills, with the ability to coach and encourage employee development. They will be responsible for managing compliance and quality assurance processes, including planning, control evaluation, testing methodologies, reporting, and issue follow-up.

Key Responsibilities:

  • Lead the Claims Compliance & Quality Assurance team, ensuring compliance with plan documents, state and federal regulations, and guidelines.
  • Develop and execute compliance and quality assurance initiatives, including risk assessment, testing & monitoring of key regulations, policies & procedures, exam preparation assistance, issue reporting, escalation, training program, corrective actions.
  • Manage and review claim-related compliance reports for accuracy.
  • Collaborate with the Claims Department, providing detailed analysis of claim review trends and insights for continuous process improvement.
  • Support carrier audits and manage escalated issues and problems.

Requirements:

  • Bachelor's degree in healthcare administration or related field or 7+ years of relevant work experience, or equivalent combination of education and experience.
  • 4+ years of leadership experience in healthcare regulatory compliance or a related field.
  • Strong understanding and ability to interpret healthcare laws and regulations.
  • Solid risk assessment capabilities.
  • Strong understanding of quality assurance standards, plan development, change control, and documentation.
  • Strong experience in insurance claims handling and administration.
  • Proficiency in medical terminology, including basic knowledge of ICD10 and CPT codes.
  • Ability to design, conduct, and report on compliance and quality activities.
  • Ability to comprehend and interpret laws/regulations with guidance from the legal department.
  • Ability to assess, prioritize, and communicate risk within claim operations.
  • Strong analytical abilities to identify root causes of issues.
  • Strong organizational skills and attention to detail.
  • Excellent written and verbal communication skills.
  • Excellent presentation and interpersonal skills.
  • Ability to thrive in a fast-paced environment, think quickly, meet deadlines, and adapt to various situations.
  • Ability to understand complex problems, identify root causes, and stay goal-oriented in a dynamic environment.
  • Ability to manage and prioritize multiple work assignments simultaneously.
  • Exhibit a strong work ethic.
  • Excellent analytical skills to proactively identify, communicate, and address potential issues.
  • Ability to work effectively with peers and business areas at all levels of the organization.
  • Strong commitment to compliance and ethics.
  • Full practical knowledge of Microsoft Office Suite.

What We Offer:

  • Competitive salary range: $80,000 to $100,000.
  • Comprehensive benefits package.
  • Opportunities for professional growth and development.

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