Job Details

Senior Compliance Analyst

Company name

Cambia Health Solutions, Inc.

Organization Type

In-House

Job Type

Legal Staff

Years of Experience

Min 4 yrs required

Location

Portland, OR

Date Last Verified

May 16,2018

Posted on

May 15,2018
Practice Area
Health Care >> Health Care
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Senior Compliance Analyst The candidate will monitor, promote and ensure compliance with all applicable state and federal laws, regulatory requirements and related company policies. Manage the development and filing of policies and forms, new product development and changes to existing products. Establish and maintain contracts with regulatory agencies. Perform independent, detailed, thorough and impartial claim reviews of life and disability claims that have been appealed to determine the disposition of denied or terminated claims. Review and respond to all DOI claims inquiries and complaints. Perform audits of claim processing work. Bachelor’s degree in writing, English, business, or health related field and 4+ years job-related work experience or equivalent combination of education and work experience. Should have compliance, claims regulatory or paralegal experience. Completion of several industry courses that lead to certification as HIA, FLMI, AIRC or CEBS preferred. Should have experience in reviewing various written materials. Develops the language and structure for all contracts, certificates and state specific provisions and amendments for all group and individual LifeMap products including COBRA and TPA administration. Files all contracts and associated forms with the insurance departments of the states in which LifeMap is licensed to do business, insuring that all such documents are in compliance with federal and state laws and regulations and that the correct filing transmittals and required certifications are complete and accurate. Responds to all correspondence from state insurance departments concerning filing disapprovals, including researching the applicability of the statute or regulation on which disapproval is based, revising and refiling forms if it is determined that the disapproval is warranted, and corresponding with the insurance department to present our interpretation if we do not agree that the disapproval is warranted. Designs and develops auxiliary forms such as group applications, health statement applications, enrollment forms and other associated materials for new products and plans. Reviews and edits correspondence drafted by the reinsurers, the Claims Department and other LifeMap departments. Corresponds with attorneys regarding claim and contract issues. Researches, analyzes and interprets insurance laws and regulations to determine their impact on LifeMap products, practices and administrative procedures and makes recommendations as to procedural changes and/or product revisions. Researches issues for various departments, and acts as a resource for LifeMap Home Office and Regional Office staff with regard to policy, procedure, state mandates, and insurance department requirements. Makes sound judgments and acts and communicates effectively as a result of those judgments without immediate supervision from a legal department. Determines if legal department review is needed on complex issues. Drafts and/or assists the contract analysts to draft nonstandard (customized or negotiated) contracts and “takeover” contracts that clearly, concisely and accurately describe the level of risk being accepted by the LifeMap underwriters. Acts as subject matter expert, provides assistance and training to junior team members and staff of other LifeMap departments on an individual and group basis. Reviews and audits work done by junior team members. Supports product development/maintenance activity, providing highly technical advice on language and regulatory issues. Responds to insurance commissioner complaints by conducting an extensive review the of claim file, developing a chronology of the actions taken and the decisions made, and providing a detailed explanation of the reasons for the claim decision. Evaluates if prior actions and decisions were appropriate and makes recommendations. Performs independent, detailed, thorough and impartial claim reviews that have been appealed to determine the disposition of denied or terminated claims. Determine if appropriate policy and procedures were followed on appeal reviews; evaluates compliance and determines if medical, contractual and other information was applied appropriately and if claim outcomes are supported by the information and documentation within the claim. Perform claim appeal reviews within timeframes governed by ERISA, meet internal quality and operating standards and other compliance and legislative requirements. Conduct claim audits using established criteria and quality sampling methodology. Prepare audit reports and distribute to management and leadership. Maintain databases containing audit information.

Additional info

Requisition ID: 2018-24541

Company info

Hiring Coordinator
Cambia Health Solutions, Inc.
100 SW Market Street
Portland, OR 97201

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