Senior Compliance Specialist – Payment Integrity

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🕒 Junho 6

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Vālenz® Health

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 2004

⚕️ Seguro de Saúde

💳 Fintech

☁️ SaaS

Healthcare Insurance • Fintech • SaaS

A Vālenz® Health é uma provedora de soluções abrangentes para planos de saúde que oferece uma plataforma totalmente integrada, projetada para simplificar as complexidades do setor de saúde para empregadores, pagadores, provedores e membros. A empresa foca em aumentar a qualidade e reduzir custos por meio de insights baseados em dados, navegação para membros, redes de provedores e gestão robusta de sinistros. Ao conectar diversos stakeholders no ecossistema de saúde, a Vālenz busca melhorar os resultados de saúde e otimizar a experiência de saúde para todos os envolvidos.

Descrição

• Serve as the primary compliance liaison for Payment Integrity and Payment Operations, providing strategic guidance on regulatory and operational compliance matters. • Interpret, analyze, and operationalize applicable regulatory requirements, including the No Surprises Act (NSA), Fraud, Waste & Abuse (FWA) laws, CMS requirements, and state Department of Insurance (DOI) regulations impacting payment and billing practices. • Provide compliance oversight and guidance related to payment workflows, reimbursement methodologies, claims administration processes, and product development initiatives. • Partner cross-functionally with operational leaders to identify, assess, and mitigate financial and regulatory compliance risks associated with payment and claims functions. • Monitor and evaluate emerging regulatory developments, enforcement trends, and industry guidance to determine operational impact and support implementation of required changes. • Support the development, review, implementation, and maintenance of financial and payment-related policies, procedures, and standard operating procedures (SOPs). • Participate in high-risk initiatives, system implementations, process enhancements, and product changes to ensure compliance considerations are appropriately addressed. • Assist with incident response activities involving payment disputes, FWA-related escalations, regulatory inquiries, and other compliance-related matters. • Support internal audits, external audits, client audits, and regulatory examinations by coordinating documentation, responding to inquiries, and ensuring audit readiness. • Collaborate with Corporate Compliance and cross-functional stakeholders on issue intake, triage, investigation support, tracking, corrective action planning, and resolution activities. • Develop and deliver training, education, and compliance guidance to internal stakeholders regarding applicable regulatory requirements, policies, and operational expectations. • Maintain accurate and organized documentation supporting compliance oversight activities, monitoring efforts, investigations, and audit preparedness.

🎯 Requisitos

• Bachelor’s degree required; concentration in Healthcare Administration, Finance, Business Administration, or a related field preferred • 5+ years of progressive experience in healthcare compliance, payment integrity, regulatory compliance, or related healthcare operations • Certified Professional Coder (CPC) credential or equivalent coding certification • Demonstrated knowledge and experience with claims processing operations and/or payment integrity programs • Demonstrated knowledge of healthcare billing, coding, and reimbursement regulations • Demonstrated experience with Fraud, Waste & Abuse (FWA) compliance frameworks and investigative processes • A plus if you have... Experience supporting No Surprises Act (NSA) implementation, oversight, and compliance activities. Experience within Payment Integrity, health plan, payer-side, or managed care operations

🏖️ Benefícios

• Competitive benefits package with generous employer subsidies • Flexible and remote working options • 401k with generous employer match and immediate vesting • Personal and professional development opportunities • Supportive family benefits, including paid leave for new family members • Companywide philanthropic program, Valenz Communities Connection