Senior Medical and Financial Risk Evaluation Professional

5 hours ago

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Humana

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Healthcare Insurance

Humana is a healthcare company dedicated to making a positive impact on the health of individuals, communities, and the healthcare system as a whole. With a focus on putting health first, Humana serves a diverse range of populations, including seniors and the military, providing Medicare Advantage HMO, PPO, and PFFS plans. Humana is committed to fostering a culture of belonging and mutual respect, offering competitive and flexible benefits to ensure the financial security of its employees and their families. The company prides itself on creating an inclusive workplace where everyone has the opportunity to succeed.

10,000+ employees

Founded 1961

⚕️ Healthcare Insurance

📋 Description

• supporting the development, implementation and monitoring of medical/financial risk • identifying, assessing, and mitigating any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events • performing routine quality audits on PPI data mining partner concepts to determine payment accuracy • acting as a liaison between internal areas and PPI business partners • leading business partner conference calls and meetings • providing training for PPI data mining business partners • reporting/resolving security and system issues for external vendors • monitoring partner quality and providing ad hoc reports as needed • identifying data trends, developing solutions to improve processes, assisting with presenting and implementing recommendations and solutions • leading or participating in cross-functional projects

🎯 Requirements

• Bachelors Degree • Minimum of 3 years of medical claims auditing experience (interpreting if claims initially paid correctly in the system) • Minimum of 2 years Provider Payment Integrity (formally known as Financial Recovery) experience • CAS claims knowledge • Prior vendor relationship experience/knowledge • Intermediate knowledge with Microsoft Excel and Power Point • Ability to confidently communicate verbally and via email with external vendor partners • Demonstrated strong emotional intelligence • Strong relationship building skills • Ability to self-start and prioritize on assignments given / research oriented • Experience with cross-functional project management, including summarization of project status, and presentation to leadership

🏖️ Benefits

• medical, dental and vision benefits • 401(k) retirement savings plan • time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave) • short-term and long-term disability • life insurance