Senior Claims Compliance Professional

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct oversight audits of claims delegates to ensure compliance with state and federal regulations as well as Humana standards.

• Act as the main point of contact for designated claims delegates.

• Perform audits on medical, mental health, and vision claims.

• Monitor, report, and communicate audit findings to both delegates and internal departments.

• Prepare comprehensive audit reports and present results to management and stakeholders.

• Examine delegate policies, procedures, and claims files for precision, completeness, and adherence to compliance.

• Validate coding, billing methods, and documentation against regulatory and legislative requirements.

• Develop and implement corrective action plans, monitoring their execution until resolution.

• Foster and maintain relationships with assigned delegates.

• Keep records of oversight activities, audit outcomes, and compliance status.

• Utilize data analysis tools and audit software to observe trends and enhance quality assurance.

• Collaborate with claims processors and compliance teams to address issues and refine processes.

• Create and update delegated oversight policies, procedures, and training materials.

• Assist in preparation for regulatory audits and accreditation evaluations.

• Support special projects aimed at enhancing departmental efficiency.

⛳️ Requirements

• Minimum of 2 years of experience in claims and/or auditing.

• Comprehensive knowledge and understanding of claims processes.

• Capability to effectively represent Humana with a high degree of professionalism when interacting with external delegates.

• Proficient in MS Word, Excel, and PowerPoint.

• Familiarity with regulatory and legislative requirements, including state and federal regulations as well as accreditation standards.

• Outstanding oral and written communication skills, including the ability to present audit findings and persuade delegates to address deficiencies.

• Willingness to travel up to 20% of the time.

• Preferred: Bachelor's degree.

• Experience with delegation laws, regulations, and accreditation standards, such as CMS, NCQA, and applicable state requirements.

• Background in claims auditing, specifically in medical, mental health, or vision claims.

• Working knowledge of coding standards (ICD, CPT, and HCPCS).

• Familiarity with audit methodologies, including sampling, root cause analysis, and the use of scorecards or dashboards.

• Experience utilizing data analysis or audit tools to track trends and bolster quality assurance.

• Experience in project coordination or management.

• Skilled in metrics and report development.

• Experience in vendor management.

• Relevant certifications such as CHC, CCEP, CPC, CIA, or CFE are advantageous.

🏝️ Benefits

• Bonus incentive plan based on individual and/or company performance.

• Comprehensive 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 coverage.

• Life insurance.

• Flexible work-from-home or hybrid work arrangements.

• Occasional travel to Humana offices for training or meetings.

• Support for internet service requirements for home or hybrid employees.