Claims Compliance Manager

Claims Compliance Manager We exist for workers and their employers -- who are the backbone of our economy.  That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. 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 submi ... (truncated, view full listing at source)