Healthcare Compliance & Claims Oversight Specialist

Western Health Advantage; Sacramento (CA); Ibrido; USD 72.000 - 85.000; Tempo pieno

Descrizione del lavoro

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.

Competenze

• 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.

Mansioni

• 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.

Conoscenze

Regulatory knowledge

Project coordination

Data analysis

Communication

Formazione

Bachelor's degree in Compliance

Strumenti

Microsoft Office

SmartSheet

SCAN/Cognos

Descrizione del lavoro

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.