Claims Compliance Manager

Verana HealthWorkFromHome

Stellenbeschreibung:

Location

Remote

Employment Type

Full time

Location Type

Remote

Department

Claims

Compensation

$115K – $125K • Offers Equity • Offers Bonus

Pay Transparency
To determine our base salary range, we consider as many of the following data points as are available to us: external market, salary survey data, internal data in terms of comparable roles and our budget for the position. Compensation is both an art and a science (as is negotiating a salary for a new job at a new company!), so what we have posted is our good faith estimate of a fair range for what we expect to pay.

We encourage candidates to apply for positions that are of interest and share their desired salary. We consider that as an additional data point, along with candidate skills and qualifications as part of our process. Candidates who apply that are over our budget will not be considered unless they have experience that far exceeds the requirements for our positions where that additional experience has a benefit to the business which we will assess during our recruiting process..

Summary of role

The Compliance Manager – Health Care Claims serves as the organization's subject matter expert (SME) on regulatory compliance matters pertaining to self-funded and level-funded health plan products administered through our Third Party Administrator (TPA) platform. This role is responsible for the end-to-end ownership of all mandated compliance reporting obligations, ensuring timely and accurate delivery to clients, plan sponsors, and all designated regulatory bodies. The ideal candidate brings deep operational knowledge of federal health care compliance requirements and thrives in a fast-paced environment where regulatory landscapes evolve frequently.

Responsibilities Include

Regulatory Reporting & Filing

Own and execute all CMS Section 111 (MSP) mandatory insurer reporting obligations, including coordination of data collection, submission, and error resolution; serve as the primary point of contact for CMS inquiries related to Section 111 reporting

Manage RxDC (Prescription Drug and Health Care Spending) reporting under the Consolidated Appropriations Act (CAA), including both D2 Medical and P2 Medical data files; coordinate with pharmacy benefit managers (PBMs), stop-loss carriers, and internal teams to compile and submit accurate annual reports on behalf of plan sponsors

Prepare and submit annual PCORI (Patient-Centered Outcomes Research Institute) fee filings for applicable self-funded plans, ensuring accurate calculation of covered lives and timely IRS Form 720 support

Maintain a compliance reporting calendar and monitor all regulatory deadlines; proactively communicate status updates and filing confirmations to clients and internal stakeholders

Transparency & Disclosure Compliance

Administer the Gag Clause Prohibition Attestation process under the CAA; collect required data, submit annual attestations to CMS/EEOC on behalf of plan sponsors, and maintain documentation of compliance

Lead Transparency in Coverage (TiC) compliance efforts, including oversight of machine-readable file (MRF) production and publication requirements, and coordination with vendors and clients to meet all applicable mandates

Support the development and maintenance of Preferred Networks disclosures and related plan document language to ensure alignment with regulatory standards

Assist in the drafting and review of Summary Plan Descriptions (SPDs) and Summaries of Benefits and Coverage (SBCs), ensuring all documents reflect current plan designs, regulatory requirements, and plain-language standards

No Surprises Act (NSA) & IDR Support

Serve as the internal SME on No Surprises Act (NSA) compliance, including Good Faith Estimate (GFE) requirements, Explanation of Benefits (EOB) standards, and balance billing protections

Manage and coordinate NSA negotiations for out-of-network claims subject to the open negotiation process; partner with claims leadership and legal counsel to support Independent Dispute Resolution (IDR) proceedings, including submission preparation, documentation, and tracking of outcomes

Fraud, Waste & Abuse (FWA) Management

Serve as a key contributor to the organization's Fraud, Waste & Abuse program, monitoring claims data for patterns, anomalies, and indicators of potential FWA activity across self-funded and level-funded plan populations

Coordinate the flagging and suspension of suspect claims within the claims administration platform, ensuring appropriate holds, documentation, and chain-of-custody protocols are followed prior to escalation

Liaise with the FBI, OIG, and other applicable law enforcement or regulatory agencies when suspected fraud rises to the level requiring external referral; prepare and submit referral documentation in accordance with agency requirements and organizational policy

Maintain and distribute FWA activity reports to clients and appropriate parties, including summary findings, claim dispositions, and recovery outcomes where applicable

Collaborate with Special Investigations Unit (SIU) resources, external audit partners, and stop-loss carriers on coordinated investigations

Stay current on common FWA schemes in the health care claims space (e.g., upcoding, unbundling, phantom billing, provider fraud rings) and educate internal teams and clients accordingly

Client Advisory & SME Responsibilities

Act as the primary claims compliance resource for clients, brokers, and consultants on all regulated reporting topics listed above; respond to inquiries with accuracy and in a timely manner

Develop and deliver client-facing compliance guides, reporting summaries, deadline calendars, and educational materials to support plan sponsor understanding and accountability

Distribute all required reports and filings to clients and agreed-upon parties (TPAs, stop-loss carriers, brokers, CMS, etc.) in accordance with compliant timelines and contractual obligations

Monitor regulatory guidance from CMS, DOL, IRS, HHS, and other agencies; translate new requirements into actionable operational procedures for internal teams and clients

Internal Operations & Process Development

Build, document, and continuously improve internal workflows, SOPs, and controls for each compliance program area

Collaborate cross-functionally with Claims, IT, Account Management, Legal, and Finance to ensure data integrity and operational readiness for all compliance deliverables

Identify and elevate compliance risks proactively; recommend corrective action plans as needed

Support audit requests and regulatory examinations related to compliance reporting programs

Qualifications

Required Skills and Abilities

5 years of experience in health care compliance, with specific exposure to self-funded and/or level-funded group health plans in a TPA environment

Demonstrated, hands‑on expertise with CMS Section 111 reporting, RxDC D2/P2 reporting, Gag Clause Attestation, TiC/MRF compliance, PCORI filings, and NSA/IDR processes

Strong understanding of ERISA, ACA, HIPAA, and the Consolidated Appropriations Act (CAA) as they apply to self-insured health plans

Experience drafting or reviewing SPDs and SBCs in compliance with DOL and ACA requirements

Proven ability to manage multiple concurrent regulatory deadlines with a high degree of accuracy and accountability

Excellent written and verbal communication skills; able to translate complex regulatory requirements into clear guidance for clients and non‑compliance audiences

Proficiency with Microsoft Office Suite; experience with claims systems and compliance tracking tools

Regulatory Acumen – Maintains current, working knowledge of federal health care regulations and applies them operationally

Preferred Qualifications

Bachelor's degree in Health Care Administration, Business, Paralegal Studies, or a related field; advanced degree or relevant certifications (CEBS, CHC, CSFS) a plus