Claims Compliance Manager, TPA

FirstEnroll; Alpharetta (GA); On-site; USD 120,000 - 160,000; Full time

Job summary

Heathos is seeking a Claims Compliance Manager to oversee regulatory and operational compliance in a health Claims TPA environment. You will partner with Claims Operations, Vendor Management, and Leadership to ensure compliant repricing, adjudication, and reporting, with a focus on risk identification and controls.

The role emphasizes building documented controls, supporting regulatory inquiries, and developing audit tools to monitor claims processes across the organization.

Qualifications

• 5+ years of experience in a health Claims TPA environment.
• Direct experience with claims processing workflows.
• Working knowledge of: State TPA regulatory frameworks; Claims adjudication and repricing; HIPAA Privacy & Security Rules; ERISA fundamentals.
• Experience responding to regulatory inquiries or audits preferred
• Ability to translate operational processes into documented controls

Responsibilities

• Regulatory Oversight- Claims Activities and regulatory monitoring.
• Monitor compliance with state TPA statutes and regulations applicable to health claims administration.
• Evaluate whether operational activities constitute claims adjudication, adjustment, or repricing under applicable law.
• Support state licensing inquiries and DOI responses related to claims operations.
• Maintain regulatory inventory specific to claims handling requirements.
• Review end-to-end claims workflows and ensure they are documented.
• Identify compliance risk in claims processes including multiplier/fee schedule applications and communications to members/providers.
• Ensure EOB language and format meet regulatory requirements.
• Validate adherence to contractual authority limitations.
• Develop and implement a claims-specific monitoring program.
• Track corrective actions and remediation timelines.
• Develop audit tools for sample claim file reviews and repricing timeliness

Skills

Regulatory awareness

Attention to detail

Listening&documentation

Team collaboration & communication

5+ years health Claims TPA experience

Job description

Job Title

Claims Compliance Manager, TPA

Department

Compliance

Reports to

Sr. Director of Compliance

Location

GA (Alpharetta)

About Heathos

Heathos is transforming the healthcare insurance landscape through a connected, data-driven ecosystem that simplifies complexity and drives long-term success. Built on trust, innovation, and integrity, we provide technology, services, and insights that support agencies, carriers, and members at every stage. Our family of brands—FirstEnroll, AdminOne, and SonicMarketing—works together to streamline operations and deliver a seamless insurance experience.

Position Summary

The Claims Compliance Manager is a functional compliance manager responsible for oversight of regulatory and operational compliance within a health Claims Third-Party Administrator (TPA) environment. This role partners directly with Claims Operations, Network Repricing, Vendor Management, and Leadership to ensure that claims administration activities, including repricing, adjudication, EOB issuance, vendor coordination, and regulatory reporting, are conducted in compliance with applicable state TPA laws, HIPAA, ERISA (as applicable), and contractual obligations. The ideal candidate has prior Claims TPA experience and understands the operational realities of claims intake and processing, including but not limited to, 837/835 workflows, fee schedule application, repricing methodologies, EOB production, and delegated vendor oversight. This is a functional leadership role (not a people-manager position initially), responsible for building controls, documenting processes, and proactively identifying risk.

Core Responsibilities

• Regulatory Oversight- Claims Activities
• Monitor compliance with state TPA statutes and regulations applicable to health claims administration
• Evaluate whether operational activities constitute claims adjudication, adjustment, or repricing under applicable law
• Support state licensing inquiries and DOI responses related to claims operations
• Maintain regulatory inventory specific to claims handling requirements
• Claims Process Control and Risk Review
• Review and ensure end-to-end claims workflows are accurately documented
• Identify compliance risk in:
• Multiplier or fee schedule applications
• Claims communications to members/providers
• Ensure EOB language and format meet regulatory requirements
• Validate adherence to contractual authority limitations
• Audit and Monitoring Program Development
• Build and execute a claims specific compliance monitoring program
• Track corrective action items and remediation timelines
• Develop audit tools for:
• Sample claim file reviews
• Repricing validation Timeliness standards

Qualifications

• 5+ years of experience in a health Claims TPA environment
• Direct experience with claims processing workflows
• Working knowledge of:
  • State TPA regulatory frameworks
  • Claims adjudication and repricing
  • HIPAA Privacy & Security Rules
  • ERISA fundamentals
• Experience responding to regulatory inquiries or audits preferred
• Ability to translate operational processes into documented controls

Key Competencies

• Accuracy and attention to detail
• Regulatory awareness
• Listening and documentation skills
• Dependability and consistency
• Team collaboration and communication

Heathos is proud to be an equal opportunity and affirmative action employer. We are committed to building a workforce that is representative of the agencies, carriers, and members we serve, creating a culture of belonging, and providing an equal employment opportunity regardless of race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, criminal histories consistent with legal requirements, or any other basis protected by law. See also Know Your Rights: Workplace Discrimination is Illegal .

If you have a need that requires accommodation, please let us know here .

Heathos is a binational company and, in order to facilitate efficient collaboration and communication binationally, English proficiency is a requirement for all roles unless stated otherwise in the job posting.