Claims Compliance Analyst

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Description

We are seeking a Claims Compliance Analyst to join our client’s team! This is a fully remote position with a great company offering fantastic benefits. The Claims Compliance Analyst is responsible for maintaining a deep knowledge of the claim processes, processing claims, and ensuring compliance with internal company policies and procedures. The ideal candidate manages the entire claims process from start to finish, including the implementation, auditing, and execution of compliance activities related to claims.

The Claims Compliance Analyst will collaborate with various departments to assess compliance risks, controls, and implement new regulations affecting the claims team. In this role, you will:

• Work within systems like Reg Ed to review assigned tasks and implement new laws, rules, and regulations.
• Collaborate cross-departmentally to understand and implement regulations using systems such as Reg Ed.
• Maintain an in-depth understanding of the claim adjudication process.
• Process claims accurately and timely, analyzing submitted medical treatments and coverage terms.
• Stay informed on state and federal health insurance regulations and mandates.
• Serve as a subject matter expert (SME) on products and systems.
• Create, execute, and audit compliance items related to claims, including risk assessments, testing, monitoring, and training materials.
• Assist in market conduct exams by reviewing claim-related tasks.
• Develop procedures for regulatory items impacting claims requiring special handling.
• Participate regularly in compliance meetings.
• Review claim-related compliance reports for accuracy.
• Scrub pay-related reports to determine the correct claim date and penalties/interest.
• Handle claim adjustments related to regulatory requirements.
• Perform other duties as assigned.

Requirements

Our ideal candidate will have:

• At least 5 years of experience in health insurance claim processing.
• Experience in planning, executing, and documenting compliance self-monitoring initiatives.
• Strong understanding of complex laws and regulations.
• Ability to assess, prioritize, and communicate claims risks.
• Problem-solving skills to identify root causes and remain goal-oriented.
• Excellent analytical, written, verbal, and interpersonal skills.
• Ability to work efficiently in a fast-paced environment, prioritize tasks, meet deadlines, and adapt to changing situations.
• Ability to work independently and collaboratively across departments and levels.

• Mid-Senior level

• Full-time

• Legal

• Renewable Energy
• Semiconductor Manufacturing

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