Compliance UM Coordinator

Virginia, United States

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Not SpecifiedCompensation

Junior (1 to 2 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Candidates must possess a minimum of 1 year of data entry experience and demonstrate strong verbal and written communication skills. Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint), navigating multiple systems, and basic technical troubleshooting is required. Preferred qualifications include experience in healthcare Utilization Management, issuing adverse benefit determination or approval letters, knowledge of medical terminology, coding systems (ICD10, CPT4, HCPC), Power BI, QikBase, QView, Medicaid Utilization Management, and a Certified Nurse Assistant or Medical Assistant background.

Responsibilities

The Compliance (UM) Coordinator 2 is responsible for issuing notice of adverse benefit determination and approval letters for Medicaid Utilization Management authorization determinations in accordance with accreditation, contractual, and organizational requirements. This role involves analyzing report data to identify compliance risks, meeting production and quality metrics, and collaborating with teammates to ensure team success. The coordinator works independently on semi-routine assignments and performs necessary computations.

Skills

Data Entry

Verbal Communication

Written Communication

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

System Navigation

Technical Troubleshooting

Healthcare Utilization Management

CGX

Adverse Benefit Determination Letters

Approval Letters

Medical Terminology

ICD10

CPT4

HCPC Codes

Power BI

QikBase

QikView

Medicaid Utilization Management

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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