• Claims FDR Delegation Oversight Specialist

    Job Locations US-RI-Smithfield
    Req No.
    NHPRI Department
    700 - Claims
    Regular Full-Time
  • Overview

    (FDR = First Tier, Downstream and Related Entities)

    This position will lead, coordinate and participate in all delegation oversight audits of the company’s vendors, service providers and delegated subcontracted providers, according to regulatory and contractual requirements, specifically focusing on claim processing activities.

    He/she will assist in the liaison role between the subcontracted providers in the delegation oversight process. The position will also participate in audits, develop reports regarding audits, and analyze, track and trend claim audit findings. This position will review all claim Service Level Agreement (SLA) results, identify any metrics not meeting expectations, make recommendations for remediation and/or identify the need for appropriate corrective action.  

    He/She will lead, coordinate and monitor all claim Corrective Action Plans (CAP) and Continuous Improvement Projects (CIP) for FDRs whether associated with audit findings or operational issues. 

    He/She will engage in the strategic development of the Claims FDR Oversight Program.


    • Ensure that vendors understand their responsibilities under the company’s Code of Business Conduct
    • Ensure that the company’s relationships with its vendors, suppliers, first tier entities, downstream entities and related entities are compliant with applicable Federal and State laws and regulations
    • Track and ensure that delegated oversight protocols are conducted according to the Delegation Oversight Policies and Procedures
    • Maintain accurate recordkeeping of all delegation oversight activities and ensure all SLAs are met
    • Assist in the revision of delegation oversight audit tools in accordance with standards established by CMS, RI EOHHS and company policy, as required
    • Other duties as assigned
    • Performs other duties as assigned Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.



    • Bachelor degree with emphasis in business, health administration, or related field or comparable years (5+) experience in Federal and/or State regulatory compliance
    • 5+ years’ experience in claims processing with progressive increases in both experience and responsibility; working understanding of benefits, contract and transaction systems, and general adjudication knowledge required
    • CMS regulations and Managed Care knowledge and experience
    • Extensive medical coding, physician billing, and fraud and abuse auditing experience; In-depth knowledge of coding practices for professional and institutional claims
    • HIPAA Privacy regulatory knowledge
    • Demonstrated effective general writing skills and business report writing skills
    • Ability to establish, nurture and maintain strong and effective working relationships internally and externally
    • Ability to maintain detailed and accurate records
    • Ability to build audit and oversight programs from the ground up
    • Proficiency with PC applications including Microsoft Office (Word, Excel & Outlook)

    Core Company-Wide Competencies:

    • Communicate Effectively
    • Respect Others & Value Diversity
    • Analyze Issues & Solve Problems
    • Drive for Customer Success
    • Manage Performance, Productivity & Results
    • Develop Flexibility & Achieve Change 

    Job Specific Competencies:

    • Attend to Detail & Improve Quality
    • Influence & Negotiate
    • Plan & Organize
    • Exercise Sound Judgement & Decision Making

    FDR Oversight:

    • Business Lead Level:

    In the role of business lead for assigned FDR; incumbent is responsible to complete comprehensive oversight and monitoring of their vendor that incorporates the following elements: efficient and effective operations; compliance with laws, regulations, policies, procedures; and other company performance issues designed to reduce risk and add value to the company


    Travel Expectations:

    • Local Travel Required

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org.



    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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