Payment Integrity Professional

About the Role

Become a part of our caring community and help us put health first. The Payment Integrity Professional 2 contributes to overall cost reduction by utilizing code editing guidelines and data anomalies to ensure correct claim payment. The Payment Integrity Professional 2 work assignments require in-depth research, cross-departmental collaboration, and independent determination of the appropriate courses of action.

Ready for a career move? The Payment Integrity Professional 2 contributes to overall cost reduction by utilizing coding knowledge to identify/validate new code edit opportunities in a timely fashion to ensure claims process correctly the first time. Expert-level coding knowledge specific to Medicare and Medicaid guidelines is a must. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Fosters relationships between Code Edit Management, internal stakeholders, and multiple external code editing vendors. Drives process improvements and ensures successful run of business. Follows established guidelines/procedures.

Use your skills to make an impact.

Work Style and Hours

• Work Style: 100% remote/work at home.
• Work Hours: Typical business hours are Monday-Friday, 8 hours/day, 5 days/week. Associates are expected to start each day between 6 AM-9 AM in their own time zone.

Required Qualifications

• Certified Professional Coder with either AHIMA or AAPC certification
• Minimum of 2 years of experience utilizing coding guidelines, submitting, reading and/or interpreting claims
• Distinguished knowledge of American Medical Association Current Procedural Terminology (CPT®), Healthcare Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD) code sets.
• Exceptional understanding of Centers for Medicare & Medicaid Services (CMS) guidelines, state Medicaid guidelines, correct-coding initiatives, national benchmarks and industry standards.
• Working knowledge of Microsoft Office Programs: Word, PowerPoint, and Excel
• Proficient in managing diverse priorities, adept at swiftly transitioning between tasks based on urgency and demand
• Analytical thinking
• Strong attention to detail
• Can work independently and determine appropriate courses of action
• Ability to operate in a fast-paced, agile, metric-driven operational setting
• Capacity to maintain confidentiality
• Excellent communication skills both written and verbal
• Comfortable presenting to a large audience

Preferred Qualifications

• Experience using code editing vendor tools
• Experience leading projects and/or processes
• Ability to maintain a positive mindset
• Knowledge of Microsoft Office Programs Access and Humana systems
• Experience in a fast-paced, metric-driven operational setting
• Familiarity with Humana Code Editing Processes

Additional Information

• Internet Service: To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership.
• Internet Reimbursement: Associates who live and work from Home in the states of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Telephone Equipment: Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work Environment: Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.