Manager, Claims Compliance
Company: Bright Health
Location: Diamond Bar
Posted on: September 23, 2022
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
- Prepares and responds to departmental requests regarding
regulatory reporting and audits, settlements, and other compliance
- 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
- Maintain up-to-date knowledge of licensing, rules and
regulatory guidelines and requirements to ensure compliance of the
- 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.
- Strong communication skills, both verbal and in
- Strong attention to detail and maintains a culture of
continuous process improvement
- Ability to use resources appropriately and escalate concerns
- 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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