[Remote] Medicaid Reconciliation Professional II at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, Medicaid, InsuranceIndustries

Requirements

Undergraduate degree
Minimum 3 years of experience in Medicaid reconciliation, enrollment, or healthcare claims auditing
Minimum 3 years of experience with process improvement initiatives or change management in a healthcare setting
Demonstrated experience with data analysis and reporting tools (e.g., Excel, Access, or similar)
Proficiency in Microsoft Office Suite, especially Excel (pivot tables, VLOOKUP, formulas)
Familiarity with Medicaid systems, claims platforms, and reconciliation tools
Work-at-home requirements: minimum download speed of 25 mbps and upload speed of 10 mbps (wireless, wired cable, or DSL suggested; satellite, cellular, or microwave only if approved by leadership)

Responsibilities

Analyze and evaluate the effectiveness of existing Medicaid business processes, focusing on eligibility, enrollment, claims, and compliance workflows
Develop sustainable, repeatable, and measurable improvements aligning with Medicaid program requirements and regulatory standards
Interpret Medicaid-specific policies and data, exercising independent judgment to address operational inefficiencies, system discrepancies, or member-level variances
Collaborate with cross-functional teams, including state agencies, managed care organizations, and internal stakeholders, to drive process enhancements
Gather and evaluate Medicaid eligibility data to identify discrepancies and opportunities for process optimization and state submissions
Collaborate with Senior Professionals and Leads to recommend and implement business practices that improve reconciliation efficiency, reduce errors, and support regulatory compliance
Assess how new systems and tools can streamline Medicaid reconciliation processes and support automation efforts, sharing feedback with Senior Business Systems Analysis Associate for fix implementation
Ensure reconciliation processes align with departmental, organizational, Medicaid, and healthcare compliance strategies
Exercise independent judgment in routine tasks and contribute to problem-solving in ambiguous situations with minimal supervision
Follow established procedures while identifying areas for improvement and innovation
Meet Key Performance Indicators (KPIs): Reconciliation Accuracy Rate, Timeliness of Reconciliation, Error Reduction Rate, Process Improvement Implementation, and Compliance Rate

Skills

Key technologies and capabilities for this role

Medicaid reconciliationprocess improvementdata analysiseligibility verificationclaims processingregulatory compliancefinancial reconciliationworkflow optimizationpolicy interpretationcross-functional collaboration

Questions & Answers

Common questions about this position

What is the employment type for this position?

This is a full-time position.

What are the key responsibilities of the Medicaid Reconciliation Professional II?

Key responsibilities include data collection and analysis of Medicaid eligibility data, process enhancement through collaboration and recommendations, technology integration for streamlining processes, strategic alignment with goals, decision-making with independent judgment, and guideline adherence with improvements.

What skills are required for this role?

The ideal candidate should possess strong attention to detail to identify and resolve discrepancies, the ability to interpret and apply Medicaid policies and procedures, independent judgment, and skills in data analysis, process optimization, and collaboration with cross-functional teams.

What are the key performance indicators for this position?

KPIs include Reconciliation Accuracy Rate (percentage of accurately reconciled claims and payments), Timeliness of Reconciliation (average time to complete cycles within deadlines), Error Reduction Rate (year-over-year decrease in errors), and Process Improvement Implementation (number of processes implemented).

What makes a strong candidate for this Medicaid Reconciliation Professional II role?

A strong candidate has experience analyzing Medicaid processes like eligibility, enrollment, claims, and compliance, with skills in data analysis, process improvement, technology integration, independent decision-making, and collaboration across teams including state agencies.

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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