The ideal candidate for this role is tasked with assessing and refining the claims operation's processes and protocols, ensuring strict adherence to internal, state, and federal regulations. The role entails conducting both regular and targeted audits to ensure compliance with company standards and best practices within the accident & health and voluntary benefits sectors. Beyond compliance, the role involves mentoring team members, identifying educational needs, fostering professional development, and handling queries to enhance staff capabilities. Moreover, the candidate will be responsible for ensuring that all project and departmental targets are achieved within the allocated budgets.

Key Responsibilities:

• Collaborate with legal and compliance teams to effectively implement and manage both new and existing regulations using systematic approaches.
• Keep abreast of ongoing changes in benefits and claims handling regulatory environments.
• Gain and maintain a comprehensive understanding of relevant insurance regulations at both state and federal levels.
• Formulate and implement compliance policies, initiatives, and procedures that align with applicable laws and industry norms, ensuring they are well communicated across all operations.
• Oversee the claims compliance team to maintain accuracy, legitimacy, and timeliness of compliance measures based on regulatory documents, policies, and procedures.
• Execute internal audits to consistently meet regulatory standards.
• Conduct risk assessments, identify the fundamental issues, and implement corrective measures.
• Provide in-depth operational analysis to promote continuous improvement and enhanced efficacy within claim operations.
• Manage recruitment processes, performance assessments, career progression, retention strategies, and termination procedures in partnership with HR and higher management.
• Encourage personnel to take proactive steps in their professional development.
• Handle full spectrum of compliance activities, including planning, evaluating controls, testing methodologies, compiling reports, and following up on issues.
• Discover and implement strategies for continual process improvements that ensure compliant operations.
• Build and maintain productive relationships across all management levels to facilitate a collaborative approach to compliance.
• Develop, orchestrate, and review compliance activities such as risk assessments, essential regulatory tests, and procedure monitoring; assist with examinations, issue reporting, resolving escalations, training, and corrective measures.
• Regularly engage in compliance meetings and manage complex issues and dilemmas.
• Oversight of the collection of documents for regulatory examinations.
• Adhere to established performance metrics.
• Set and achieve strategic objectives that align with company goals, ensuring successful outcomes.
• Undertake additional responsibilities as required.

Candidate Profile:

• A Bachelor’s degree in Healthcare Administration or a related field, supplemented by at least 3 years’ relevant experience or an equivalent blend of education and experience.
• At least four years of demonstrated leadership in healthcare regulatory compliance or a related area.
• A minimum of 2 years experience in project management.
• Profound understanding and interpretation skills concerning healthcare regulations.
• Robust capability in risk assessment and quality assurance practices.
• Extensive experience in insurance claims management and administration.
• Well-versed in medical terminology with knowledge of ICD10 and CPT codes.
• Skilled in designing, conducting, and documenting compliance-related activities.
• Capacity to understand and interpret laws and regulations as laid out by legal teams.
• Effective at assessing, prioritizing, and communicating operational risks.
• Strong analytical skills to identify and resolve issues efficiently.
• Excellent communication and interpersonal skills, with an ability to present information clearly and persuasively.
• Able to handle a fast-paced environment, managing multiple tasks simultaneously to meet deadlines.
• Demonstrates integrity and a solid commitment to ethical practices and compliance.
• Proficient in working collaboratively within all levels of an organization.
• Competent in Microsoft Office Suite.

This role is suited to a highly meticulous, proactive, and dedicated individual, committed to upholding and enhancing compliance standards across company operations.