Remote Senior Manager, Claims Compliance & CMS Readiness

CareMore Health Management Services, LLC; California; Hybrid; USD 130,000 - 195,000; Full time

Benefits offered by this job

3 weeks PTO

Medical, Dental, Vision coverage

401(k) with match

Employee Wellness

Other Employee Discounts

Job summary

Mosaic Health is seeking a Senior Manager, Claims Health Plan Readiness to lead regulatory compliance, audit readiness, and payment integrity across claims operations. This fully remote role requires aligning CMS and health plan requirements with operational practices and cross-functional collaboration across Compliance, Finance, IT, and Clinical Operations.

The ideal candidate will have extensive CMS knowledge, 8–10 years in healthcare claims, and 3–5 years in leadership, with a proven ability

Qualifications

• Bachelor's degree in a related field or equivalent relevant experience.
• 8–10+ years of progressive healthcare claims, adjudication, reimbursement, or regulatory compliance experience.
• 3–5+ years of leadership experience managing teams, team leaders, or complex cross-functional operational programs.
• Extensive knowledge of CMS requirements and health plan regulatory compliance, including Medicare, Medicaid, managed care, coding standards, and claims administration systems.
• Hands-on experience leading claims-related health plan and CMS audits, including audit preparation, documentation and evidence coordination, audit responses, remediation, and corrective action follow-through.
• Strong analytical, communication, people leadership, and change management skills.

Responsibilities

• Regulatory compliance strategy and governance: Develop and execute claims health plan readiness strategies with regulatory compliance and health plan and CMS audit readiness as core priorities.
• Claims operations and compliance leadership: Lead multiple teams or functional workstreams supporting compliant claims adjudication, reimbursement accuracy, health plan and CMS audits, and corrective action execution.
• Health plan and CMS audit leadership: Lead the preparation, coordination, and execution of claims-related health plan and CMS audits, including Medicare, Medicaid, managed care, and payer audits.
• Regulatory implementation and compliance controls: Translate CMS and other applicable regulatory changes into scalable policies, claims system requirements, operating procedures, and quality controls.
• Compliance issue resolution and corrective actions: Direct the analysis and resolution of systemic adjudication errors, denials, coding issues, payment discrepancies, and recurring findings.
• Systems and payment integrity improvement: Sponsor enhancements to claims systems, workflows, automation, payment integrity, and coding controls.
• Compliance monitoring and audit reporting: Establish and monitor metrics to assess claims performance, audit readiness, and corrective action progress.
• People leadership and cross-functional partnership: Lead resource planning, team performance, coaching, and development across multiple functions.

Skills

Regulatory compliance

CMS audits

Leadership

Cross-functional collaboration

Education

Bachelor's degree

Advanced degree

CBCS credential

Tools

Facets

QNXT

EDI 837/835

Job description

Mosaic Health is seeking a Senior Manager, Claims Health Plan Readiness to lead regulatory compliance, audit readiness, and payment integrity across claims operations. This fully remote role requires aligning CMS and health plan requirements with operational practices and cross-functional collaboration across Compliance, Finance, IT, and Clinical Operations.

The ideal candidate will have extensive CMS knowledge, 8–10 years in healthcare claims, and 3–5 years in leadership, with a proven ability