Manager, Provider Compliance Full Time NEW

Manager, Provider Compliance

Brighton Health Plan Solutions

Remote – 100%

Full Time

About the Role

Brighton Health Plan Solutions is seeking an experienced Manager of Provider Compliance to lead and oversee the investigation and resolution of provider disputes related to the No Surprises Act. The Manager of Provider Compliance is responsible for directing and reviewing all determination responses to ensure full compliance with established No Surprises Act guidelines and regulatory requirements. This role provides leadership and subject matter expertise to the Provider Compliance team, ensuring consistent, accurate and timely outcomes. The ideal candidate will be skilled in healthcare claims processing, including both professional and facility claims, and well as deep experience in healthcare provider contract negotiation. This is a remote position.

Primary Responsibilities

• Oversee all aspects of the No Surprises Act to ensure ongoing regulatory compliance.
• Provide strategic oversight and thorough review of QPA claims, negotiations and agreements, and Independent Dispute Resolution (IDR) determinations.
• Conduct and guide advanced claim research including professional, facility and ancillary claims.
• Lead provider contract research, including rate analysis and negotiation communications.
• Assist in interdepartmental communication to guarantee high quality and timely expedition of requests.
• Guide and monitor Continuity of Care process and customer-specific communication to ensure regulatory alignment.
• Support provider directory accuracy initiatives to strengthen data integrity and compliance.
• Maintain tracking systems and dashboards to deliver ongoing reporting and actionable insights to executive leadership team.
• Address complex, unstructured issues using conceptual and analytical problem-solving skills.
• Identify trends and contribute strategic recommendations to enhance customer experience, improve productivity and reduce operational risk.
• Drive process and system enhancements to align with evolving regulatory requirements, using NSA outcomes and data analysis to inform decision-making.
• Maintain broad knowledge of MagnaCare’s client products and services.

Essential Qualifications

• Ability to maintain a professional demeanor under pressure.
• Capable of managing multiple complex issues.
• High School Diploma or GED diploma; Bachelor Degree preferred.
• Strong knowledge of the No Surprises Act.
• Ability to meet expected production standards and government mandated timeframes.
• Strong knowledge of provider contracts, medical terminology, payment policies and procedures, and professional and facility claims processing.
• Advanced analytic abilities.
• 3+ years computer medical billing and/or claims adjudication systems experience.
• 1+ year provider contracting negotiation experience.
• Previous experience handling appeals and grievances a plus.
• Excellent written and oral communication skills.
• Interpersonal and negotiation skills with a demonstrated ability to prioritize tasks as required.
• Effective interpersonal skills, including the ability to promote teamwork.
• Proficient in Microsoft Office Suite- specifically Microsoft Word and Microsoft Excel.
• Ability to maintain a professional demeanor under pressure.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all of your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions.

Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

JOB ALERT FRAUD: We have become aware of scams from individuals, organizations, and internet sites claiming to represent Brighton Health Plan Solutions in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All of our career opportunities are regularly published and updated brighonthps.com Careers section. If you have already provided your personal information, please report it to your local authorities. Any fraudulent activity should be reported to: recruiting@brightonhps.com