Claims Compliance Analyst

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August 19

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The MH Group (ManeHire)

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HR Tech • Recruitment • B2B

The MH Group (ManeHire) is a staffing and recruitment company that specializes in providing temporary and direct-hire employment services across various sectors. They work with clients from small businesses to large corporations, offering a wide range of staffing solutions such as administrative support, finance and accounting, human resources, healthcare, customer experience, nonprofit, real estate, and light industrial sectors. The company focuses on creating a talent recruitment pipeline, skill evaluations, reference checks, interview coordination, and ensuring work eligibility and background checking. Their services are designed to meet the unique needs of each client by tailoring recruitment processes and ensuring a perfect candidate fit.

11 - 50 employees

👥 HR Tech

🎯 Recruiter

🤝 B2B

📋 Description

• 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.

🎯 Requirements

• 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.