Senior Claims Compliance Professional

🕒 Ontem

🇺🇸 Estados Unidos – Remoto (EUA)

💵 $86.300 - $118.700 / ano

⏰ Tempo Integral

🟠 Sênior

🚔 Conformidade

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• Aberta há 1 dia.
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Humana

SiteLinkedInTodas as Vagas

10.000+ funcionários

Fundada em 1961

🏥 Saúde

🛡️ Seguros

⚕️ Seguro de Saúde

Healthcare • Insurance • Healthcare Insurance

A Humana é uma empresa de saúde dedicada a gerar um impacto positivo na saúde de indivíduos, comunidades e do sistema de saúde como um todo. Com foco em colocar a saúde em primeiro lugar, a Humana atende a uma ampla e diversa gama de populações, incluindo idosos e militares, oferecendo planos Medicare Advantage (HMO, PPO e PFFS). A Humana está comprometida em promover uma cultura de pertencimento e respeito mútuo, oferecendo benefícios competitivos e flexíveis para garantir a segurança financeira de seus funcionários e de suas famílias. A empresa se orgulha de criar um ambiente de trabalho inclusivo, no qual todos têm a oportunidade de ter sucesso.

Descrição

• Perform oversight audits of claims delegates for compliance with state and federal regulations and Humana standards • Serve as the primary point of contact for assigned claims delegates • Audit medical, mental health and vision claims • Track, report and communicate audit information to delegates and internal departments • Prepare detailed audit reports and present findings to management and stakeholders • Review delegate policies, procedures and claims files for accuracy, completeness and compliance • Validate coding, billing practices and documentation against regulatory and legislative requirements • Issue corrective action plans and monitor implementation through resolution • Develop and maintain relationships with assigned delegates • Maintain documentation of oversight activities, audit results and compliance status • Use data analysis tools and audit software to monitor trends and support quality assurance • Collaborate with claims processors and compliance teams to resolve issues and improve processes • Develop and update delegated oversight policies, procedures and training materials • Support readiness for regulatory audits and accreditation surveys • Assist with special projects that promote department efficiency

🎯 Requisitos

• 2+ years of claims and/or audit experience • Knowledge/understanding of claims • Ability to effectively represent Humana with a high level of professionalism when working with external delegates • Proficient knowledge of MS Word, Excel and PowerPoint • Knowledge/understanding of regulatory and legislative requirements, including state and federal regulations and accreditation standards • Excellent oral and written communication skills, including the ability to present audit findings and influence delegates to resolve deficiencies • Ability to travel 20% • Preferred: Bachelor’s degree • Experience with delegation laws, regulations and accreditation requirements, such as CMS, NCQA and applicable state requirements • Claims auditing experience, including medical, mental health or vision claims • Working knowledge of coding standards (ICD, CPT and HCPCS) • Experience with audit methodology, including sampling, root cause analysis and scorecards or dashboards • Experience using data analysis or audit tools to monitor trends and support quality assurance • Project coordination or management experience • Metrics and report development experience • Vendor management experience • Certifications such as CHC, CCEP, CPC, CIA or CFE

🏖️ Benefícios

• Bonus incentive plan based on company and/or individual performance • Medical, dental and vision benefits • 401(k) retirement savings plan • Paid time off • Company and personal holidays • Paid parental and caregiver leave • Short-term and long-term disability • Life insurance • Work-from-home or hybrid work arrangement • Occasional travel to Humana offices for training or meetings • Internet service requirements/support for home or hybrid employees

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