Senior Claims Regulatory Compliance Specialist

The  Claims Regulatory and Medicare Senior Specialist for Workers’ Compensation and Commercial Auto is responsible for overseeing compliance with state and federal regulations related to Workers’ Compensation and Commercial Auto claims adjudication.  This role involves analyzing claims data, ensuring adherence to regulatory standards, filing all relevant data calls required for all states as well as collaborating with various departments to enhance operational efficiency and regulatory compliance. The claims regulatory compliance role is essential to navigate the complex landscape of regulations while ensuring protection to minimize risks, and promoting operational excellence within the claims management process.

How You’ll Do It

Regulatory Compliance:

• Monitor and interpret state and federal regulations governing Workers’ Compensation and Commercial Auto Claims.   Procedures must comply with applicable laws and regulatory requirements.
• Prepare, document, analyze for accuracy and communicate responses to all regulatory reporting agencies.
• Conduct comprehensive research on relevant laws, regulations and industry best practices to inform compliance strategies.

Medicare Compliance:

• Ensure compliance with Medicare Secondary Payer (MSP) regulations and guidelines related to workers’ compensation and commercial auto claims.  This involves staying up-to-date with Medicare regulations and guidelines and implementing them into the claims handling process.
• Communicate and coordinate with the Centers for Medicare and Medicaid Services (CMS),  Medicare Administrative Contractors (MAC) and Section 111 to report and resolve Medicare-related issues and inquiries.
• Review workers’ compensation and commercial auto claims to identify potential Medicare beneficiaries and assess the need for Medicare reporting and compliance.  Analyzing claim details, medical records, and treatment plans to assist the claims team in determining the primary payer responsibility.
• Generate and submit required reports and documentation to Medicare and other relevant authorities.  This may include reporting claims information, tracking payments made, and ensuring accurate and timely report of any changes or updates to claim status.

Data Analysis:

• Analyze workers’ compensation and commercial auto claims data to identify trends, compliance issues, and opportunities for improvement.
• Prepare detailed reports for management, highlighting regulatory compliance status and recommending actionable solutions.

Compliance Audits and Investigation:

• Develop, implement and update policies and procedures related to workers’ compensation and commercial auto claims to reflect regulatory changes.
• Working collaboratively with Pie’s legal counsel and other stakeholders in executing all responsibilities and in supporting and advancing compliance.
• Collaboration with our Claims Learning & Development team to drive continuing education on compliance related issues
• Develop compliance reporting best practices and drive action plans for improvement based off leading indicators and evidence-based findings.

The Right Stuff

• Bachelor’s Degree is required. AIC, ARM, CWCP are preferred.
• 10 years of industry experience within a carrier or TPA insurance environment with expertise in workers’ compensation and commercial auto.
• 5 years of experience with regulatory filings and Medicare regulations. Understanding and practical application of complex regulations within the casualty insurance environment.       
• 5 years of prior experience in conducting audits, assessments or investigations in a compliance capacity for casualty claims.
• Experience in promoting a culture of compliance and best in class claims management practices.
• Keen eye for detail to ensure all aspects of compliance are thoroughly examined and addressed.  Strong desire to ask questions, seek feedback, and understand new concepts related to compliance and claims management. Advanced problem solving skills, to be able to manage complex situations with multiple layers, and resolve to solution anticipating needs now and into the future.  Proficient in gathering and analyzing information to determine the root causes of compliance issues. 
• In depth knowledge of the claims lifecycle, including submission, assessment, adjudication and appeals in workers’ compensation and commercial auto claims.
• Advanced capability to develop innovative solutions to compliance related challenges with a growing organization. Willingness to embrace change and adapt to evolving environment.   Openness to attending training, workshops or conferences to enhance knowledge and skills in regulatory space. Receptive to diverse perspectives and ideas that can lead to improved compliance strategies.       
• Proficient in reviewing documentation and processes to ensure alignment with regulatory standards.  Skilled in communicating effectively with regulatory agencies and responding to inquiries and audits. Foster a culture of compliance by promoting awareness and understanding of regulatory obligations to internal stakeholders.
•  Ability to work independently and provide support for multiple claims regions/ teams.
• G-Suite, Collaboration tools (Slack is preferred). Expert knowledge of regulatory frameworks.  Skilled in synthesizing information from various sources to support compliance reporting.        
• Documentation and Record-Keeping: Maintaining accurate and detailed documentation for all Medicare compliance activities and data call reporting, including communication logs, reports, audits, training and any other required documentation.  Collaborates with underwriting, vendors or claim adjusters utilizing various methods to obtain and provide information related to regulatory reporting. Must have a strong ability to prioritize tasks and focus.  Strong capability to conduct investigations into compliance violations or complaints, ensuring thorough and impartial resolution.   
• Commitment to identifying and implementing improvements in compliance process and practices.
• Exhibits deep knowledge regarding Medicare Section 111 reporting, insurance, claims operations, regulatory compliance requirements, and associated applications.  Knowledge of current trends and changes in the insurance and claims landscape, including emerging technologies and regulatory updates.        
• Partners with internal legal team to manage and coordinate responses to regulator inquiries.  Reviews responses to determine if any follow-up actions are necessary to modify processes, procedures, or behaviors in the Claims organization.  Assists the EDI Data Management role in understanding regulations related to data gathering and reporting.       
• Up to 10% of travel may be required in this position.