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Manager, Claims Compliance

Company: Bright Health
Location: Diamond Bar
Posted on: September 23, 2022

Job Description:

General Scope
The Manager, Claims Compliance is responsible for monitoring the workflow and the workforce associated with processed claims, reviewing payment accuracy, timeliness and operational processes consistent with the rules, regulations and guidelines of the regulatory and governing bodies of the plan. This position is responsible for preparing and responding to requests received from the Legal, Member Services, Compliance, and Finance departments, including but not limited to claims recovery, subrogation, direct member reimbursement, and settlements.
Duties and Responsibilities

  • Ensure that all the policies and procedures are being followed and, when necessary, assists in verifying compliance.
  • Oversees the claims recovery process, including subrogation.
  • Prepares and responds to departmental requests regarding regulatory reporting and audits, settlements, and other compliance related activities.
  • Review audited closed claims/files to ensure compliance with internal quality expectations and regulations.
  • Identifies and monitors claims areas and processes lacking the necessary operational controls as well as related resource/staffing utilization that could become potential "control" issues.
  • Provide periodic benefit and regulatory updates to department, mentor individuals, share best practices, audit procedures and controls to ensure compliance with the organization and statutory requirements.
  • Maintain up-to-date knowledge of licensing, rules and regulatory guidelines and requirements to ensure compliance of the staff.
  • Coordinates with other departments regarding rules, regulations and guidelines surrounding the Claims Department, and any updates established by the ruling and governing bodies.
  • Interacts with Appeals and Grievance and HEDIS teams as well as any Maximus action, activities and reporting.
  • Conducts quarterly meetings, presentations and reports indicating the current status of our compliance efforts and any glaring needs (if any). Other duties as assigned.


    • Minimum of five years of Medicare claims processing, internal/external claims audit experience is preferred
    • Previous experience with preparing for Medicare Advantage regulatory audits or requesting payment recoveries
    • Knowledge of claims payment methodologies
    • Proficient in reviewing and interpretation of medical terminology, CPT, ICD10, revenue codes, HCPCS codes, contract terms, and DOFR
    • Experience with EZ-CAP system claims module.

      Personal Qualities

      • Strong communication skills, both verbal and in writing.
      • Strong attention to detail and maintains a culture of continuous process improvement
      • Ability to use resources appropriately and escalate concerns when appropriate.
      • Must be a strong team player, punctual, dependable, and able to work under time constraints.
      • Ability to interact with all levels of management.
      • Ability to set priorities, problem solve, and manage multiple demands effectively in a fast-paced environment.
      • Must possess the ability to educate and train staff members & other departments as needed.
      • Possess an appreciation of cultural diversity.
      • Maintains a positive demeanor, effectively lead team/department meetings and assist the department in identifying areas of opportunity while assisting in driving solutions.
      • Willingness to accept responsibility and desire to learn a new task and able to look at challenges as opportunities.
      • Strong interest in learning opportunities with a goal to move into progressive leadership roles

Keywords: Bright Health, Diamond Bar , Manager, Claims Compliance, Executive , Diamond Bar, California

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