Claims Compliance & QA Manager - The MH Group

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Health Insurance Experience is required

Remote Opportunity

This position is responsible for overseeing the day-to-day activities of the Claims Compliance & Quality Assurance team. The primary focus is to ensure compliance with state and federal regulations and adherence to industry best practices for accident & health and voluntary benefits. The position involves reviewing processes and practices for continuous improvement, tracking claim quality reports, and developing compliance and quality assurance policies and procedures. The role includes providing coaching, identifying training needs, and assisting staff with questions. The successful candidate must work closely with the compliance team to assess risks and controls, communicate new regulations impacting claims, and ensure milestones and goals are met within approved budgets.

Minimum Qualifications:

• 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.

Essential Job Duties and Responsibilities:

1. Lead the Claims Compliance & Quality Assurance team, ensuring compliance with plan documents, state and federal regulations, and guidelines.
2. Adhere to internal key performance metrics.
3. Identify operating plan goals and ensure deliverables are met.
4. Collaborate with the Claims Department, providing detailed analysis of claim review trends and insights for continuous process improvement.
5. Support carrier audits.
6. Conduct hiring, employee performance reviews, promotions, retention, and termination activities in consultation with management and HR.
7. Perform risk analysis, determine root causes, and recommend corrective actions.
8. Coach and encourage employee development.
9. Manage compliance and quality assurance processes, including planning, control evaluation, testing methodologies, reporting, and issue follow-up.
10. Identify opportunities for continuous process improvement to enhance quality claim handling.
11. Cultivate collaborative relationships with all levels of management.
12. Stay current with benefits and regulations impacting claims handling.
13. Demonstrate a detailed understanding of state/federal insurance regulations and mandates.
14. Work with legal and compliance to implement new and existing regulations using the regulatory system.
15. Develop, execute, and audit claim-related compliance initiatives (e.g., risk assessment, testing & monitoring of key regulations, policies & procedures, exam preparation assistance, issue reporting, escalation, training program, corrective actions).
16. Participate in recurring compliance meetings.
17. Manage and review claim-related compliance reports for accuracy.
18. Manage escalated issues and problems.
19. Gather claim documentation for market conduct exams.
20. Perform other duties as assigned.

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Essential Job Duties and Responsibilities:

1. Lead the Claims Compliance & Quality Assurance team, ensuring compliance with plan documents, state and federal regulations, and guidelines.
2. Adhere to internal key performance metrics.
3. Identify operating plan goals and ensure deliverables are met.
4. Collaborate with the Claims Department, providing detailed analysis of claim review trends and insights for continuous process improvement.
5. Support carrier audits.
6. Conduct hiring, employee performance reviews, promotions, retention, and termination activities in consultation with management and HR.
7. Perform risk analysis, determine root causes, and recommend corrective actions.
8. Coach and encourage employee development.
9. Manage compliance and quality assurance processes, including planning, control evaluation, testing methodologies, reporting, and issue follow-up.
10. Identify opportunities for continuous process improvement to enhance quality claim handling.
11. Cultivate collaborative relationships with all levels of management.
12. Stay current with benefits and regulations impacting claims handling.
13. Demonstrate a detailed understanding of state/federal insurance regulations and mandates.
14. Work with legal and compliance to implement new and existing regulations using the regulatory system.
15. Develop, execute, and audit claim-related compliance initiatives (e.g., risk assessment, testing & monitoring of key regulations, policies & procedures, exam preparation assistance, issue reporting, escalation, training program, corrective actions).
16. Participate in recurring compliance meetings.
17. Manage and review claim-related compliance reports for accuracy.
18. Manage escalated issues and problems.
19. Gather claim documentation for market conduct exams.
20. Perform other duties as assigned.

Compensation $80,000 to $100,000h