Claims Compliance Program Manager

Job DescriptionA bit about this role:

The Claims Compliance Program Manager will oversee and support our claims compliance activities, operational quality initiatives, and audit readiness. Reporting to the Claims Compliance Senior Program Manager, you will monitor key performance indicators, partner cross-functionally to address compliance gaps, reinforce operational and regulatory standards across claims operations (including Medicare Advantage and Medicaid), and drive project tracking and issue resolution.

Your Responsibilities will include:

• Monitor claims compliance activities, KPIs, and reports to identify trends, risks, operational gaps, and areas for improvement.
• Coordinate and document internal, financial, and regulatory audits.
• Analyze claims data to identify discrepancies and recurring issues.
• Track compliance issues, deliverables, Jira tasks, and audit findings, collaborating cross-functionally to ensure timely remediation.

• Support quality assurance operations, including audit workflows, operational reporting, and data validation.
• Develop and update policies, procedures, and related compliance materials.
• Escalate compliance concerns and control deficiencies to management.

• Participate in risk assessments to strengthen internal controls.

• Collaborate across Claims, Payment Integrity, and Compliance teams to investigate issues.
• Evaluate workflow gaps and recommend practical solutions to mitigate risks.
• Support the implementation and oversight of corrective action plans.

• Identify opportunities to improve the efficiency, accuracy, and consistency of assigned compliance activities.
• Assist with AI initiatives and automation projects in claims compliance operations.

Required skills and experience:

• Organization Skills: Proven ability to manage multiple priorities, support operational monitoring activities, and ensure timely tracking of compliance deliverables and issue resolution.
• Communication Skills: Strong interpersonal and verbal communication skills to effectively collaborate across teams and engage with cross-functional stakeholders on audit and compliance findings.
• Writing Skills: Proficient in drafting clear, precise, and structured compliance reports, summaries, and official audit documentation.
• Process Documentation: Experience in developing, updating, and standardizing standard operating procedures (SOPs), policies, and workflow documentation.
• Bachelor's degree required, or equivalent work experience.

Desired skills and experience:

• Experience in healthcare, healthcare technology, or tech operations, preferred