Claims Compliance Manager

Centivo•Buffalo, NY

4d•Hybrid

About The Position

We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Summary of role: The Compliance Manager – Health Care Claims serves as the organization's subject matter expert (SME) on regulatory compliance matters pertaining to self-funded and level-funded health plan products administered through our Third Party Administrator (TPA) platform. This role is responsible for the end-to-end ownership of all mandated compliance reporting obligations, ensuring timely and accurate delivery to clients, plan sponsors, and all designated regulatory bodies. The ideal candidate brings deep operational knowledge of federal health care compliance requirements and thrives in a fast-paced environment where regulatory landscapes evolve frequently.

Requirements

5 years of experience in health care compliance, with specific exposure to self-funded and/or level-funded group health plans in a TPA environment
Demonstrated, hands-on expertise with CMS Section 111 reporting, RxDC D2/P2 reporting, Gag Clause Attestation, TiC/MRF compliance, PCORI filings, and NSA/IDR processes
Strong understanding of ERISA, ACA, HIPAA, and the Consolidated Appropriations Act (CAA) as they apply to self-insured health plans
Experience drafting or reviewing SPDs and SBCs in compliance with DOL and ACA requirements
Proven ability to manage multiple concurrent regulatory deadlines with a high degree of accuracy and accountability
Excellent written and verbal communication skills; able to translate complex regulatory requirements into clear guidance for clients and non-compliance audiences
Proficiency with Microsoft Office Suite; experience with claims systems and compliance tracking tools
Regulatory Acumen – Maintains current, working knowledge of federal health care regulations and applies them operationally

Nice To Haves

Bachelor's degree in Health Care Administration, Business, Paralegal Studies, or a related field; advanced degree or relevant certifications (CEBS, CHC, CSFS) a plus
Familiarity with stop-loss insurance structures and their interaction with self-funded compliance obligations
Experience working directly with CMS COBSTP/BCRC systems for Section 111 submissions
Experience working Javelina, Health Rules Payor and/or Ringmaster platforms
Prior experience presenting compliance topics to employer plan sponsors, brokers, or advisory committees

Responsibilities

Regulatory Reporting & Filing
Own and execute all CMS Section 111 (MSP) mandatory insurer reporting obligations, including coordination of data collection, submission, and error resolution; serve as the primary point of contact for CMS inquiries related to Section 111 reporting
Manage RxDC (Prescription Drug and Health Care Spending) reporting under the Consolidated Appropriations Act (CAA), including both D2 Medical and P2 Medical data files; coordinate with pharmacy benefit managers (PBMs), stop-loss carriers, and internal teams to compile and submit accurate annual reports on behalf of plan sponsors
Prepare and submit annual PCORI (Patient-Centered Outcomes Research Institute) fee filings for applicable self-funded plans, ensuring accurate calculation of covered lives and timely IRS Form 720 support
Maintain a compliance reporting calendar and monitor all regulatory deadlines; proactively communicate status updates and filing confirmations to clients and internal stakeholders
Transparency & Disclosure Compliance
Administer the Gag Clause Prohibition Attestation process under the CAA; collect required data, submit annual attestations to CMS/EEOC on behalf of plan sponsors, and maintain documentation of compliance
Lead Transparency in Coverage (TiC) compliance efforts, including oversight of machine-readable file (MRF) production and publication requirements, and coordination with vendors and clients to meet all applicable mandates
Support the development and maintenance of Preferred Networks disclosures and related plan document language to ensure alignment with regulatory standards
Assist in the drafting and review of Summary Plan Descriptions (SPDs) and Summaries of Benefits and Coverage (SBCs), ensuring all documents reflect current plan designs, regulatory requirements, and plain-language standards
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, including submission preparation, documentation, and tracking of outcomes
Fraud, Waste & Abuse (FWA) Management
Serve as a key contributor to the organization's Fraud, Waste & Abuse program, monitoring claims data for patterns, anomalies, and indicators of potential FWA activity across self-funded and level-funded plan populations
Coordinate the flagging and suspension of suspect claims within the claims administration platform, ensuring appropriate holds, documentation, and chain-of-custody protocols are followed prior to escalation
Liaise with the FBI, OIG, and other applicable law enforcement or regulatory agencies when suspected fraud rises to the level requiring external referral; prepare and submit referral documentation in accordance with agency requirements and organizational policy
Maintain and distribute FWA activity reports to clients and appropriate parties, including summary findings, claim dispositions, and recovery outcomes where applicable
Collaborate with Special Investigations Unit (SIU) resources, external audit partners, and stop-loss carriers on coordinated investigations
Stay current on common FWA schemes in the health care claims space (e.g., upcoding, unbundling, phantom billing, provider fraud rings) and educate internal teams and clients accordingly
Client Advisory & SME Responsibilities
Act as the primary claims compliance resource for clients, brokers, and consultants on all regulated reporting topics listed above; respond to inquiries with accuracy and in a timely manner
Develop and deliver client-facing compliance guides, reporting summaries, deadline calendars, and educational materials to support plan sponsor understanding and accountability
Distribute all required reports and filings to clients and agreed-upon parties (TPAs, stop-loss carriers, brokers, CMS, etc.) in accordance with compliant timelines and contractual obligations
Monitor regulatory guidance from CMS, DOL, IRS, HHS, and other agencies; translate new requirements into actionable operational procedures for internal teams and clients
Internal Operations & Process Development
Build, document, and continuously improve internal workflows, SOPs, and controls for each compliance program area
Collaborate cross-functionally with Claims, IT, Account Management, Legal, and Finance to ensure data integrity and operational readiness for all compliance deliverables
Identify and escalate compliance risks proactively; recommend corrective action plans as needed
Support audit requests and regulatory examinations related to compliance reporting programs