MSP Compliance Specialist - Eastern Alliance

About the role

This position supports our workers' compensation line of business, Eastern Alliance, and is hybrid, reporting to any of our Eastern Alliance office locations approximately 2 days per month. The primary responsibility is to ensure the Company’s compliance with the CMS mandatory insurer reporting requirements for Section 111 of the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Medicare Secondary Payer Act under the direction of management.

Responsibilities include managing all CMS data elements aspects for WC claims, verifying data points, and handling CMS-related inquiries such as conditional payment notices (CPNs) and Medicare Advantage liens, following established Company requirements and procedures for reporting Section 111 for Ongoing Responsibility for Medicals (ORM) and Total Payment Obligation to Claimants (TPOC) timely and accurately.

Responsibilities

• 40% - Timely and accurately conduct research and input required Section 111 data elements into WCXP/Compliance fields for quarterly submission to CMS, including Ongoing Responsibility for Medical (ORM) accepted ICD code/diagnoses and Total Payment Obligation to Claimant (TPOC)/settlement details on claims for Medicare-eligible injured workers.
• 25% - Proactively manage and update WCXP CMS Compliance claim data elements required for termination of ORM within each jurisdiction’s statute of limitations for medicals, in compliance with the CMS Non-group health plan (NGHP) reference guide. Establish and maintain diary tasks to monitor timely and accurate ORM and ORM termination for Medicare-eligible claim files. Maintain current knowledge of statutory rules around termination of benefits in each jurisdiction.
• 10% - Coordinate and resolve missing data elements or errors with the claim representative. Document Section 111 activity in claim notes following best practices.
• 15% - Monitor and handle incoming CMS correspondence and Medicare Beneficiary inquiries related to CMS development letters, conditional payment lien notices, and Medicare Advantage liens under management direction. Direct issuance of payments as appropriate.
• 5% - Maintain knowledge of CMS requirements for Section 111 reporting. Attend business unit, department, and company meetings.
• 5% - Assist with assigned Company projects and pursue professional growth through attendance at insurance-related events, seminars, classes, and conferences.

Requirements

• Bachelor’s degree is required; a High School Diploma/GED with a minimum of eight years of experience in a medical, legal, or insurance environment may substitute for the degree.
• Minimum of three years of experience in workers’ compensation claims.
• Strong working knowledge of medical terminology, common medical procedures, and treatments.
• Extensive knowledge of workers’ compensation processes and procedures, including applicable state laws.
• Working knowledge of CMS reporting requirements preferred.
• Proficiency in Microsoft Office applications (Word, Excel) and ability to learn new software.
• Attention to detail, ability to prioritize, and meet deadlines.
• Ability to handle multiple priorities simultaneously.
• Excellent organization, time management, analytical, and problem-solving skills.
• Ability to assess urgency and importance of situations and take appropriate action.
• Strong interpersonal skills, including empathy and active listening to build trust.
• Effective verbal and written communication with diverse constituencies, including agency partners, customers, injured workers, and providers.
• Ability to maintain confidentiality and operate standard office equipment.
• Ability to attend insurance and industry functions to represent the Company positively.

Benefits

Build your career with us and enjoy access to a best-in-class benefits program.

Pay

Position Salary Range: $57,575.00 - $95,008.00. The salary range represents the entirety of the pay grade for this position. Most candidates will start in the bottom half of the range. Factors determining actual salary include specific skills, years of experience, location, and comparison to other team members in this role.

Assessments

As part of the hiring process, candidates are required to complete two assessments from The Predictive Index: a Behavioral and a Cognitive assessment, each taking less than 12 minutes. These assessments help provide additional insight into work style. You will receive emails with invitations to complete these assessments after submitting your application.