Claims Compliance & Service Coordinator - Remote
PMA Companies

New York, New York

Posted in Insurance

Job Info

As a part of the TPA Operations team, the Integration & Compliance Coordinator coordinates duties related to the new account transition for the TPA and maintains responsibility for conducting compliance audits, risk assessments, investigations, education and training assignments relating to billing, coding, reimbursement and documentation of vendor monetized services.


  • Extract and integrate data from the takeover TPA/Carrier
  • Create index and point documents accordingly
  • Map Images and assist with paper image loading
  • Test code for conversion and production upload
  • Act as Subject Matter Expert on identified topics and solutions
  • Track Medicare exceptions and assist with Section 111 error resolution
  • Other account transition duties as assigned
  • Conduct ongoing quality assurance audit focused on billing of monetized services
  • Develop and implement comprehensive audit and monitoring tools and reporting templates to provide vendor oversight for all TPA functions
  • Performance of timely and effective compliance and operational reviews to assess coding, documentation and billing accuracy, identify compliance related risks, internal control weaknesses, revenue capture opportunities
  • Ensure strategic partners have a compliance plan and policies and procedures that detail compliance with billing processes. Review, monitor and report on strategic partners effective implementation of the plan.
  • Develop reference materials and provide education to the field around billing for services
  • Analyze audit data and prepare reports for review and presentation to management making recommendations for improvement
  • Assist in the development of policies and procedures that establish standards for compliance, as well as preparation of other guidance documents and tools to assist staff and strategic partners in in billing, coding and documentation
  • Determine charge corrections and refunds resulting from compliance reviews and ensure they have been completed and applied back appropriately for all parties
  • Work with internal departments to improve vendor compliance audit process
  • Complete other projects as assigned
  • Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

  • 1+ years of claims experience preferred
  • Knowledge of claims payment processes
  • Auditing/billing experience preferred
  • Ability to collaborate with may functional areas of the organization
  • Large database management skills
  • Advanced knowledge of Microsoft Office products (Excel, Power Point, Visio, Word)
  • Bachelor's Degree is preferred
  • Demonstrated written and verbal communication skills

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