Claims Business Compliance Manager

Wellfleet, a Berkshire Hathaway company, delivers customer-centric accident and health insurance, with quality service and uncompromising ethics. Wellfleet works to protect people against risk throughout every stage of life – from grade school to college to the workplace.

Founded in 1993 as Consolidated Health Plans (CHP), Wellfleet, headquartered in Springfield, Mass., is one of the nation’s leading providers of health and accident insurance products to the higher education market.

The ideal candidate in this position is responsible for evaluating the claim operation’s processes and procedures, ensuring that everything adheres to the internal guidelines and state and federal regulations. Performs regular audits and/or targeted reviews of Claim Operations to ensure compliance including but not limited to, compliance with company standards and industry best practices for Accident & Health and Voluntary Benefits . Provide coaching and identify training needs, as well as staff development and assist with staff questions. Ensures that project/department milestones/goals are met while adhering to approved budgets. W orks closely with Wellfleet’s Corporate Compliance Team to assess compliance processes, risks, controls, and implementation of new and/or changes with existing regulations that affect and impact claims.

In this role, you will…

• Collaborate with Legal and Compliance to implement new and/or existing regulations utilizing regulatory system.
• Stay current with benefits and regulations affecting claims handling.
• Maintain a detailed understanding of State/Federal insurance regulations and mandates .
• Develop and implement compliance policies, initiatives and procedures that align with relevant laws, regulations, and industry standards, ensuring these updated policies are effectively communicated throughout Claim Operations.
• Set direction and manage the efforts of the Claims Compliance Team to ensure validity, accuracy, and timeliness of compliance initiatives in accordance with plan documents, policies, procedures, and state and federal regulations.
• Conduct internal audits to ensure adherence to regulations and standards.
• Perform risk analysis, determine root cause, and recommend corrective action.
• Collaborate with claim operations by providing detailed analysis of trends and insights to ensure continuous process improvement.
• Conduct hiring, employee performance reviews, promotions, retention and termination activities in consultation with Management and HR.
• Coach and encourage others to take ownership of their development.
• Manage all aspects of compliance; including but not limited to planning, control evaluation, testing methodologies, reporting, and issue follow-up.
• Identify continuous process improvement opportunities resulting in compliant claim handling.
• Develop and cultivate collaborative relationships with all levels of management.
• Develop, execute, and audit Claim related compliance items (e.g. risk assessment, testing & monitoring of key regulations, policies & procedures, assist with exam preparation, issue reporting and escalation, training program, corrective actions).
• Participate in recurring compliance meetings.
• Manage escalated issues and/or problems.
• Manage gathering claim documentation for market conduct exams.
• Adherence to internal key performance metrics.
• Identify Operating Plan goals that are beneficial to the company and ensure deliverables are met.
• Perform other duties as assigned .
  
  
  

We are looking for candidates with…

• Bachelor's degree in healthcare administration or related field and 3+ years of relevant work experience or equivalent combination of education and experience.
• 4+ years of health care regulatory compliance leadership or related experience.
• 2+ years of project management experience.
• Strong understanding and ability to interpret healthcare laws and regulations.
• Solid risk assessment capabilities.
• Strong understanding of quality assurance standards, plan development, change control, and documentation.
• Strong insurance claims handling and administration experience.
• Medical terminology proficiency, including basic knowledge of ICD10 and CPT codes.
• Ability to design, conduct and report on compliance activities.
• Ability to digest and understand laws/regulations as interpreted by Legal Department.
• Ability to assess, prioritize and communicate risk within Claim Operations.
• Strong analytical, organizational, and problem-solving abilities to identify root cause and address issues effectively.
• Excellent written, verbal, presentation, and interpersonal communication skills.
• Capable of thriving in fast-paced environments, prioritizing multiple assignments, meeting deadlines, and adapting to various situations.
• Demonstrates a strong work ethic and commitment to compliance and ethics.
• Ability to work effectively with peers, as well as business areas at all levels of the organization.
• Proficient in Microsoft Office suite.
  
  
  

Why Wellfleet?

Here at Wellfleet, we foster a culture of growth that enables engaged and high-performing professionals to be empowered to deliver our mission and vision.

Our employees are a team devoted to providing customer service that exceeds expectations of our members and clients. Successful team members continually look for ways to improve product delivery and value.

Wellfleet offers a competitive compensation package and comprehensive benefits package including life, health and dental, vision, 401K retirement plan, short- and long-term disability coverage, flexible/dependent care spending account, tuition reimbursement, and business casual dress.

Are you interested in exploring a career at Wellfleet? Explore our open positions.

General:

Wellfleet is part of the MedPro Group family. As such, all Wellfleet team members are employees of MedPro Group Inc. We are an Equal Opportunity Employer. The annual gross base salary range is $80,000 to $100,000. This range anticipates the low and high end of the salary for this position. Actual salaries will vary and are based on factors such as a candidate’s qualifications, skills and competencies. Salary is one component of Wellfleet’s total compensation and benefits package, which includes medical, vision and dental insurance options, life and accident insurance, 401(k), and short-term and long-term disability insurance. For a more detailed overview, visit our careers website at: wellfleetinsurance.com/about/careers.