Claims Compliance Analyst

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🕒 Agosto 19, 2025

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The MH Group (ManeHire)

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11 - 50 funcionários

👥 RH Tech

🎯 Recrutamento

🤝 B2B

HR Tech • Recruitment • B2B

O Grupo MH (ManeHire) é uma empresa de recrutamento e seleção que se especializa em fornecer serviços de emprego temporário e efetivo em diversos setores. Eles trabalham com clientes que vão desde pequenas empresas até grandes corporações, oferecendo uma ampla gama de soluções de recrutamento, como suporte administrativo, finanças e contabilidade, recursos humanos, saúde, experiência do cliente, organizações sem fins lucrativos, imobiliário e setores industriais leves. A empresa foca na criação de um fluxo de recrutamento de talentos, avaliações de habilidades, verificação de referências, coordenação de entrevistas e assegurando a elegibilidade para trabalho e verificação de antecedentes. Seus serviços são projetados para atender às necessidades únicas de cada cliente, personalizando os processos de recrutamento e garantindo a escolha do candidato perfeito.

Descrição

• The Claims Compliance Analyst is responsible for maintaining a deep knowledge of the claim processes, can process claims, and is expected to comply with internal company policies and procedures. • The ideal candidate manages the entire claims process from beginning to end and the implementation, auditing, and execution of compliance activities regarding claims. • Collaborate with different departments to assess compliance risks, controls, and implement new regulations that affect the claims team. • Navigate different claims systems. • Work within systems like RegEd to review assigned tasks and implement new laws, rules, and regulations. • Work cross-departmentally to understand and implement new and/or existing regulations utilizing systems such as RegEd. • Maintain an in-depth understanding of the claim adjudication process. • Process claims by all regulations in a timely and accurate manner, including analyzing the submitted medical treatment and investigating the coverage terms. • Maintain a strong understanding of state and federal health insurance regulations and mandates. • Strong knowledge of products/systems, and a subject matter expert (SME). • Create, carry out, and audit compliance items linked to claims, including risk assessment, testing, and monitoring of important laws & regulations, rules & processes, help with exam preparation, issue reporting & escalation, training materials, and remedial measures. • Assist in market conduct exams by reviewing claim-related tasks. • Create and implement procedures for regulatory items impacting claims that require special handling. • Regularly partake in compliance-related meetings. • Review all claim-related compliance reports to ensure accuracy. • Scrub pay-related reports to accurately determine the clean claim date and proper penalties/interest. • Handle claim adjustments related to regulatory requirements. • Perform other duties as assigned.

🎯 Requisitos

• A minimum of 5 years of experience in health insurance claim processing is required. • Capacity to plan, carry out, and document compliance self-monitoring initiatives. • Ability to comprehend complex laws/regulations. • Ability to assess, prioritize, and communicate claims risk. • Ability to understand complex problems, identify root causes, and remain goal-oriented. • Strong analytical skills, with the ability to effectively identify, communicate, and address potential issues. • Strong written/verbal communication, interpersonal, and presentation skills. • Ability to work in a fast-paced environment, prioritize multiple assignments simultaneously, think quickly, meet deadlines, and adapt to various situations. • Ability to work independently, with peers, and with departments in business areas at all levels of the organization.