Claims Compliance Manager

Responsibilities

• 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
• Administer the Gag Clause 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
• Aid 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
• 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
• Support the Fraud, Waste & Abuse (FWA) 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
• 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
• Support audit requests and regulatory examinations related to compliance reporting programs

Qualifications

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