TPA Claims Compliance Lead

Heathos LLC; Alpharetta (GA); On-site; USD 110,000 - 140,000; Full time

Job summary

Heathos LLC in Alpharetta, GA seeks a Claims Compliance Manager to oversee regulatory and operational compliance in a health Claims TPA environment. The role partners with Claims Operations, Network Repricing, Vendor Management, and Leadership to ensure compliant claims processing, repricing, EOBs, and reporting.

The ideal candidate has hands-on experience with 837/835 workflows, fee schedules, delegated vendor oversight, and building controls and documented processes to identify and mitigate

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.
• Experience responding to regulatory inquiries or audits preferred.
• Ability to translate operational processes into documented controls.

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: Repricing validation Timeliness standards

Skills

Regulatory awareness

Attention to detail

Documentation skills

Teamwork and collaboration

Strong communication

Analytical thinking

Job description

Heathos LLC in Alpharetta, GA seeks a Claims Compliance Manager to oversee regulatory and operational compliance in a health Claims TPA environment. The role partners with Claims Operations, Network Repricing, Vendor Management, and Leadership to ensure compliant claims processing, repricing, EOBs, and reporting.

The ideal candidate has hands-on experience with 837/835 workflows, fee schedules, delegated vendor oversight, and building controls and documented processes to identify and mitigate