Claims Compliance Analyst

Job Title: Claims Compliance Analyst

Job Summary / Introduction
We are seeking a highly motivated and detail-oriented Claims Compliance Analyst to support Medicare regulatory compliance across P&C lines of business. The ideal candidate will have a strong understanding of Medicare regulations, particularly as they relate to property and casualty claims. This role will involve engaging with state and federal regulatory authorities while ensuring all claims processes adhere to compliance standards.

Detailed Job Description
The Claims Compliance Analyst will be responsible for ensuring compliance with Medicare regulations, including CMS guidelines and HIPAA standards. The role involves monitoring and interpreting state and federal legislation related to Medicare claims, reviewing claims data for accuracy and completeness, and submitting required reports. The Analyst will work closely with various business stakeholders, including Claims, IT, legal, and Compliance teams, to integrate compliance requirements into workflows and system updates.

Key Responsibilities

• Ensure compliance with Medicare regulations, including CMS guidelines and HIPAA privacy standards.
• Monitor state and federal legislation impacting Medicare claims and reporting requirements.
• Maintain up-to-date documentation and reference materials related to regulatory requirements.
• Review and analyze claims data for accuracy, completeness, and compliance with Medicare Section 111 reporting.
• Identify and resolve discrepancies in claims submissions, including coding issues.
• Prepare and submit reports for regulatory filings and internal compliance tracking.
• Respond to inquiries from state and federal agencies regarding claims and compliance matters.
• Maintain detailed records of compliance activities, audits, and corrective actions related to Medicare reporting.
• Collaborate with Claims business stakeholders, IT, legal, and Compliance to align on Medicare compliance initiatives.
• Support Claims BA teams in integrating compliance requirements into system updates and workflows.
• Stay informed on emerging regulations and industry best practices related to Medicare compliance.
• Perform additional claims compliance duties as assigned.

Skills & Experience

• Bachelor’s degree required.
• 2+ years of insurance claims experience in commercial lines, with workers’ compensation experience required.
• Strong knowledge of Medicare Secondary Payer (MSP) rules and CMS guidelines, including Section 111 reporting.
• Solid understanding of Ongoing Medicare Responsibility for Medicals (ORM) and Total Payment Obligation to Claimant (TPOC) reporting requirements.
• Ability to assess processes and identify key areas of risk, implementing resolution strategies and best practices.
• Strong analytical, research, organizational, and critical thinking skills.
• Ability to manage multiple projects, prioritize effectively, and interact with various stakeholders.
• Excellent communication skills with the ability to engage with staff at all levels and state regulatory authorities.
• Strong project management skills and the ability to handle complex compliance challenges.