Claims Compliance Manager, TPA

Job Title: Claims Compliance Manager, TPA

Department: Compliance

Reports to: Sr. Director of Compliance About Heathos Heathos is transforming the healthcare insurance landscape through a connected, data-driven ecosystem that simplifies complexity and drives long-term success. Built on trust, innovation, and integrity, we provide technology, services, and insights that support agencies, carriers, and members at every stage. Our family of brands—FirstEnroll, AdminOne, and SonicMarketing—works together to streamline operations and deliver a seamless insurance experience.

Position Summary: The Claims Compliance Manager is a functional compliance manager responsible for oversight of regulatory and operational compliance within a health Claims Third-Party Administrator (TPA) environment. This role partners directly with Claims Operations, Network Repricing, Vendor Management, and Leadership to ensure that claims administration activities, including repricing, adjudication, EOB issuance, vendor coordination, and regulatory reporting, are conducted in compliance with applicable state TPA laws, HIPAA, ERISA (as applicable), and contractual obligations. The ideal candidate has prior Claims TPA experience and understands the operational realities of claims intake and processing, including but not limited to, 837/835 workflows, fee schedule application, repricing methodologies, EOB production, and delegated vendor oversight. This is a functional leadership role (not a people-manager position initially), responsible for building controls, documenting processes, and proactively identifying risk. Core ResponsibilitiesRegulatory Oversight- Claims Activities Monitor compliance with state TPA statutes and regulations applicable to health claims administration Evaluate whether operational activities constitute claims adjudication, adjustment, or repricing under applicable law Support state licensing inquiries and DOI responses related to claims operations Maintain regulatory inventory specific to claims handling requirements Claims Process Control and Risk Review Review and ensure end-to-end claims workflows are accurately documented Identify compliance risk in: Multiplier or fee schedule applications Claims communications to members/providers Ensure EOB language and format meet regulatory requirements Validate adherence to contractual authority limitations Audit and Monitoring Program Development Build and execute a claims specific compliance monitoring program Track corrective action items and remediation timelines Develop audit tools for: Repricing validation Timeliness standardsQualifications 5+ years of experience in a health Claims TPA environment Direct experience with claims processing workflows Working knowledge of: State TPA regulatory frameworks Claims adjudication and repricing HIPAA Privacy & Security Rules Experience responding to regulatory inquiries or audits preferred Ability to translate operational processes into documented controlsAccuracy and attention to detail Regulatory awareness Listening and documentation skills Dependability and consistency Team collaboration and communicationHeathos is proud to be an equal opportunity and affirmative action employer. We are committed to building a workforce that is representative of the agencies, carriers, and members we serve, creating a culture of belonging, and providing an equal employment opportunity regardless of race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information, veteran status, marital status, pregnancy or related condition (including breastfeeding), expecting or parents-to-be, criminal histories consistent with legal requirements, or any other basis protected by law. See also Know Your Rights: Workplace Discrimination is Illegal. If you have a need that requires accommodation, please let us know here. Heathos is a binational company and, in order to facilitate efficient collaboration and communication binationally, English proficiency is a requirement for all roles unless stated otherwise in the job posting.