Senior Claims Compliance Professional

🔥 32 minutes ago

🇺🇸 United States – Remote

💵 $86.3k - $118.7k / year

⏰ Full Time

🟠 Senior

🚔 Compliance

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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Humana

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1961

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • 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.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

• 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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