Compliance Coordinator

Description

The Compliance Coordinator – Claims Management is responsible for supporting regulatory compliance, audit readiness, and reporting functions within the Claims Department of the Managed Services Organization (MSO). This role coordinates internal and external claims audits, prepares and submits required regulatory and health plan reports, and assists in developing corrective action plans to address audit findings and compliance deficiencies.

The Compliance Coordinator ensures timely and accurate submission of health plan reporting, supports delegated oversight requirements, and maintains documentation and audit trails necessary to demonstrate compliance with federal and California regulatory requirements, including Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and Centers for Medicare & Medicaid Services (CMS) standards where applicable.

This position plays a key role in ensuring the organization maintains compliance with health plan contracts, regulatory requirements, and delegated managed care obligations.

• Minimum:
  High School Diploma or equivalent.
• Preferred:
  Associate’s or Bachelor’s degree in Healthcare Administration, Business Administration, Compliance, or related field.

• Minimum:
  At least two years of healthcare administrative, claims, or compliance experience.
• Preferred:
  Three or more years of managed care, MSO, IPA, or health plan experience. Experience supporting claims audits, delegated oversight, or regulatory reporting. Experience working with claims systems such as EZ Cap or similar platforms.

• Preferred:
  Certified Professional Compliance Officer (CPCO) or Certified in Healthcare Compliance (CHC)

• Knowledge of managed care claims processes and regulatory requirements.
• Knowledge of DMHC, CMS, DHCS, and health plan regulatory and compliance requirements.
• Knowledge of audit processes, regulatory reporting, and delegated oversight requirements.
• Strong organizational and documentation management skills.
• Excellent written and verbal communication skills.
• Strong analytical and problem‑solving skills.
• Proficiency in Microsoft Office Suite, including Word, Excel, and Access.
• Familiarity with claims systems such as EZ Cap preferred.
• Ability to maintain confidentiality and data integrity.
• Ability to manage multiple priorities and meet regulatory deadlines.
• Ability to work independently and collaboratively.

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. Work is primarily performed in an office or hybrid office environment and requires prolonged sitting, computer use, and document review.

The role requires sustained attention to detail, organization, and analytical thinking to ensure compliance and audit readiness. Occasional lifting of materials up to approximately 10–20 pounds may be required. This role requires the ability to maintain confidentiality and professionalism when handling sensitive claims and compliance information.