Claims & Provider Relations Oversight Specialist

Western Health Advantage; Sacramento (CA); Hybrid; USD 72,000 - 85,000; Full time

Job summary

Western Health Advantage is seeking a detail-oriented Claims & Provider Relations Oversight Specialist to support compliance and regulatory operations within our Claims and Provider Relations department.

This role ensures departmental compliance with federal and state regulations, accreditation standards, and internal policies while serving as a key resource for audits, regulatory filings, reporting, and compliance initiatives.

Qualifications

• Bachelor's degree in Compliance, Healthcare Administration, Legal or Regulatory Affairs, or a related field.
• Three years of experience in healthcare compliance, governance, auditing, quality, accreditation, or regulatory operations.
• Two years of experience with a California-based HMO in Claims and/or Provider Relations.
• One year of experience implementing compliance programs involving NCQA, Knox-Keene, HIPAA, Covered California, PCI, or similar regulatory requirements.

Responsibilities

• Coordinate compliance projects, regulatory filings, audits, and corrective action plans.
• Develop, maintain, and update departmental policies and procedures.
• Monitor compliance with federal and state regulations, NCQA standards, Knox-Keene requirements, HIPAA, and other applicable regulations.
• Review regulatory guidance, legislation, and compliance communications, providing recommendations and responses as needed.
• Support Annual Network Review (ANR), Geo Access, PAAS, PSS, after-hours surveys, and related compliance activities.
• Prepare compliance communications, provider education materials, newsletters, and handbook updates.
• Monitor, audit, and report on department performance and compliance metrics.
• Provide compliance education and training to department staff.
• Oversee external vendors and medical groups to ensure timely and accurate claims processing and provider data maintenance.
• Track corrective actions and analyze compliance trends to identify opportunities for improvement.
• Maintain organized compliance documentation and regulatory records.

Skills

Regulatory knowledge

Project coordination

Data analysis

Communication

Education

Bachelor's degree in Compliance

Tools

Microsoft Office

SmartSheet

SCAN/Cognos

Job description

Claims & Provider Relations Oversight Specialist

Western Health Advantage

Location: Sacramento, CA (Hybrid)
Salary: $72,384 – $85,000 annually
\"Purpose that inspires. Impact that improves lives. Join us in building healthier communities.\"
Western Health Advantage

Position Summary

Western Health Advantage is seeking a detail-oriented Claims & Provider Relations Oversight Specialist to support compliance and regulatory operations within our Claims and Provider Relations department. This role is responsible for ensuring departmental compliance with federal and state regulations, accreditation standards, and internal policies while serving as a key resource for audits, regulatory filings, reporting, and compliance initiatives.

The ideal candidate is organized, analytical, and collaborative, with experience in California managed care, claims and provider operations, and healthcare compliance.

What You'll Do

• Coordinate compliance projects, regulatory filings, audits, and corrective action plans.
• Develop, maintain, and update departmental policies and procedures.
• Monitor compliance with federal and state regulations, NCQA standards, Knox-Keene requirements, HIPAA, and other applicable regulations.
• Review regulatory guidance, legislation, and compliance communications, providing recommendations and responses as needed.
• Support Annual Network Review (ANR), Geo Access, Provider Appointment Availability Surveys (PAAS), Provider Satisfaction Surveys (PSS), after-hours surveys, and related compliance activities.
• Prepare compliance communications, provider education materials, newsletters, and handbook updates.
• Monitor, audit, and report on department performance and compliance metrics.
• Provide compliance education and training to department staff.
• Oversee external vendors and medical groups to ensure timely and accurate claims processing and provider data maintenance.
• Track corrective actions and analyze compliance trends to identify opportunities for improvement.
• Maintain organized compliance documentation and regulatory records.

Qualifications

• Bachelor's degree in Compliance, Healthcare Administration, Legal or Regulatory Affairs, or a related field.
• Three (3) years of experience in healthcare compliance, governance, auditing, quality, accreditation, or regulatory operations.
• Two (2) years of experience with a California-based HMO in Claims and/or Provider Relations.
• One (1) year of experience implementing compliance programs involving NCQA, Knox-Keene, HIPAA, Covered California, PCI, or similar regulatory requirements.
• Strong analytical, organizational, and communication skills.
• Intermediate proficiency with Microsoft Office applications and experience with SmartSheet, SCAN/Cognos, or similar reporting tools.
• Ability to manage multiple priorities while working independently and collaboratively.

What You'll Bring

• Strong knowledge of healthcare regulatory and accreditation requirements.
• Excellent project coordination and organizational skills.
• Experience interpreting regulatory guidance and implementing compliance initiatives.Ability to analyze data, identify compliance risks, and recommend solutions.
• Strong written and verbal communication skills with the ability to collaborate across departments and with external partners.

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. (EOE)

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you—and excellent customer service for our members.