Claims Medicare and Regulatory Compliance Specialist

Responsible for leading the development and implementation of quality/compliance/legal assessments and/or manages compliance activities to ensure effective oversight of operational risk. Briefs senior leadership on results, trends, studies, and initiatives. Recommends process improvements and escalates existing and emerging risks associated to business processes. Acts as a trusted advisor for the business and mentors' peers. Maintains a solid understanding of AmTrust's mission, vision, and values. Upholds the standards of the AmTrust organization.

Provides expert knowledge and guidance in the design, assessment, and/or implementation of the quality and compliance program.
• Performs independent assessments of highly complex business processes, state requirements, and legal activities. Expert in identifying gaps driving claim outcomes and operational efficiencies.
• Recommends and facilitates policy and procedural changes for internal practices and business processes.
• Consults with business stakeholders and advises senior leadership on assessment results, trends, studies, and initiatives/projects. Evaluates success measurements.
• Partners with Claims L&D to identify, analyze, improve, and implement targeted training solutions.
• Manages the workflow and deliverables related to regulatory activities such as market conduct exams, adjuster licensing, consumer complaints, and data calls.
• Self-directed with expert ability to balance multiple projects simultaneously.
• Advanced knowledge of the regulatory landscape, QA methodologies, and risk management principles.
• Serves as a functional expert and coach to peers and team members and acts as a resource for escalated issues of an unusual nature.
• Keeps current with market trends and demands.
• Performs other duties as assigned.

• Ensure Compliance with CMS Section 111 Reporting Requirements: Oversee accurate and timely Section 111 reporting for Medicare, including capturing and submitting data related to claimants' Medicare eligibility, total payment obligations to claimants (TPOCs), and ongoing responsibility for medicals (ORM).
• Identify and Address Missing Eligibility Data: Collaborate with claims teams to identify gaps in claimant eligibility data and implement processes to ensure accurate reporting to the Centers for Medicare & Medicaid Services (CMS), minimizing potential penalties and compliance risks.
• Monitor and Improve Reporting Processes: Develop and maintain robust workflows for CMS reporting, including validation of data submissions, resolution of errors, and ensuring compliance with updates to CMS Section 111 guidelines and thresholds.

• Bachelor's Degree in related field OR equivalent business experience.
• 5 years of related claims experience, with recent background in a quality or compliance oversight role.
• Strong oral and written communication skills with demonstrated ability to translate information in a way that is easily understood by varying audiences. Ability to influence others to facilitate change.
• Demonstrated proficiency in prioritization of work based on business requirements and capacity planning.
• Strong understanding of the procurement/sourcing process.
• Applicable compliance, risk, and/or legal designations such as ARM, CRCMP, CLMP, ARC, etc.

Preferred:

• JD or Paralegal certification.
• Experience with technical writing and has demonstrated ability in building QA/Compliance frameworks.
• Influencer that is able to work through objections to obtain approvals for required project milestones.
• Advanced data and analytics skills.
• Working knowledge of developing and monitoring KPIs and KRIs.
• Process improvement certification (i.e. Six Sigma) and/or project management certification (i.e. PMP).

This job description is designed to provide a general overview of the requirements of the job and does not entail a comprehensive listing of all activities, duties, or responsibilities that will be required in this position. AmTrust has the right to revise this job description at any time.

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