The Claims Compliance Manager plays a central role in upholding federal regulatory standards for self-funded and level-funded health plan products administered through a Third Party Administrator (TPA) platform. This position ensures accurate and timely compliance across multiple reporting and disclosure mandates, serving as the go-to expert for internal teams and external partners on evolving healthcare regulations.
What You'll Do
Lead end-to-end execution of CMS Section 111 (MSP) reporting, including data coordination, submission oversight, and resolution of errors. Serve as the primary contact for CMS inquiries related to insurer reporting. Manage annual RxDC filings under the Consolidated Appropriations Act, coordinating data collection from pharmacy benefit managers, stop-loss carriers, and internal systems for both D2 and P2 medical files.
Oversee PCORI fee calculations and IRS Form 720 support, ensuring correct counting of covered lives and on-time submissions. Maintain a comprehensive compliance calendar to track all regulatory deadlines and proactively communicate filing statuses to stakeholders. Administer the Gag Clause Prohibition Attestation process by collecting required data, submitting attestations to CMS/EEOC, and preserving compliance records.
Drive Transparency in Coverage (TiC) compliance by managing the production and publication of machine-readable files. Collaborate with vendors and clients to meet disclosure requirements and support the development of Preferred Network disclosures and plan language updates. Assist in reviewing and drafting Summary Plan Descriptions (SPDs) and Summaries of Benefits and Coverage (SBCs) to ensure alignment with current regulations and plain-language standards.
Serve as the internal authority on No Surprises Act compliance, including Good Faith Estimate protocols, Explanation of Benefits formatting, and balance billing safeguards. Coordinate open negotiations for out-of-network claims and support Independent Dispute Resolution (IDR) proceedings with legal and claims teams. Contribute to Fraud, Waste & Abuse (FWA) initiatives by analyzing claims data for suspicious patterns, initiating holds on questionable payments, and preparing documentation for law enforcement referrals when necessary.
Partner with Special Investigations Unit (SIU) teams, auditors, and carriers on joint investigations. Distribute FWA reports summarizing findings, claim resolutions, and recovery outcomes. Educate internal staff and clients on common fraud schemes such as upcoding, unbundling, and phantom billing. Act as the primary compliance liaison for clients, brokers, and consultants, responding to inquiries and delivering educational materials, reporting summaries, and deadline reminders.
Monitor regulatory updates from CMS, DOL, IRS, and HHS, translating new requirements into operational workflows. Document and refine standard operating procedures across compliance domains. Work closely with Claims, IT, Account Management, Legal, and Finance teams to ensure data accuracy and system readiness. Identify compliance risks early and recommend corrective actions. Support audits and regulatory examinations as needed.
Requirements
- Five or more years of experience in healthcare compliance, specifically with self-funded or level-funded group health plans in a TPA setting
- Direct experience with CMS Section 111, RxDC D2/P2 reporting, Gag Clause Attestation, TiC/MRF, PCORI, and NSA/IDR processes
- Working knowledge of ERISA, ACA, HIPAA, and the Consolidated Appropriations Act as they apply to self-insured plans
- Experience drafting or reviewing SPDs and SBCs per DOL and ACA guidelines
- Proven ability to manage multiple regulatory deadlines with precision
- Strong communication skills, with the ability to explain complex rules clearly to non-experts
- Proficiency in Microsoft Office Suite and claims systems
- Familiarity with compliance tracking tools and operational controls
- Demonstrated understanding of federal healthcare regulations and their practical application
Benefits
This role supports a mission-driven organization focused on transforming healthcare affordability. The culture values resilience, innovation, and mutual support. Team members operate with humility and generosity, recognizing the challenges of reimagining a complex system. Collaboration and positive reinforcement are central to sustaining progress through difficult work. Employees are encouraged to celebrate wins, provide thoughtful feedback, and energize one another through shared effort.
