Description

The Senior Claims Analyst will report directly the Vice President of Claims Compliance. Senior Claims Compliance Analyst will coordinate with the claims organization, including Third Party Administrators (TPAs). In this capacity, the Senior Claims Compliance Analyst is responsible for Regulatory Compliance and Reporting, Coordinating State Audits and Inquiries and Claim Operational Controls.  This role should proactively identify gaps and opportunity areas to ensure Claims Compliance.  The Senior Claims Compliance Analyst will have Global Services support and will be instrumental in building the Claims Compliance function.

Responsibilities:

Regulatory Compliance and Reporting

Monitor and identify relevant regulatory changes and determine potential impact to the claims organization
Communicate regularly changes to appropriate business units
Identify any required system or process changes ensure regulatory compliance and reporting
Gather data to prepare and analyze Compliance managed regulatory reports and data calls. Timely submit state specific annual/quarterly reports where required.

State Inquiry and Audit Coordination

Coordinate effective responses to any inquiries by the State Departments of insurance. Will serve as an intermediary between the business, handling entity, and the State Departments.
Coordinate Claims Audits that are conducted by the various State Departments.
Medicare Reporting and Lien Management experience
Analyze and assess audit reports and complaints that are issued by the State Departments to identify performance issues.
Review state report cards and metrics on claims processing and reporting and work with TPAs and Arch staff to remediate any issues.
Fostering working relationships with regulatory bodies and Arch business groups supporting Compliance efforts.

Claim Operational Controls            

Monitor claims operational control structure and recommend any necessary changes to controls based upon audit feedback
Drive continuous improvement and development of claim control library/documentation
Support all internal audit processes
Assist with both the development of enterprise-wide Compliance best practices and delivery of compliance training
Conduct periodic compliance quality reviews for both internal claim departments and TPAs

Experience and Required Skills:

Knowledge of state insurance regulations
Knowledge of Medicare compliance is a plus
Efficient organization and project management skills
Familiarity with Wolters Kluwer, Lexis/Nexis or similar subscription services
Proficiency with the suite of Microsoft products such as Excel, Word, PowerPoint, etc. 
Ability to effectively communicate ideas, issues and solutions.

Education:

Must have at least 5-7 years’ Claims Compliance experience.
P&C claims knowledge, and the ability to communicate effectively with external business partners. Working knowledge of SOX controls and testing is preferred.