Compliance Manager – Health Care Claims

Regulatory Reporting & Filing:

• Own and execute all CMS Section 111 (MSP) mandatory insurer reporting obligations.
• Manage RxDC (Prescription Drug and Health Care Spending) reporting under the Consolidated Appropriations Act (CAA).
• Prepare and submit annual PCORI (Patient-Centered Outcomes Research Institute) fee filings for applicable self-funded plans.

Transparency & Disclosure Compliance:

• Administer the Gag Clause Prohibition Attestation process under the CAA.
• Lead Transparency in Coverage (TiC) compliance efforts, including oversight of machine-readable file (MRF) production and publication requirements.
• Support the development and maintenance of Preferred Networks disclosures and related plan document language.

No Surprises Act (NSA) & IDR Support:

• Serve as the internal SME on No Surprises Act (NSA) compliance, including Good Faith Estimate (GFE) requirements, Explanation of Benefits (EOB) standards, and balance billing protections.
• Manage and coordinate NSA negotiations for out-of-network claims subject to the open negotiation process.
• Partner with claims leadership and legal counsel to support Independent Dispute Resolution (IDR) proceedings.