Payment Integrity Professional

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess a working knowledge of Microsoft Office Programs including Word, PowerPoint, and Excel. Strong attention to detail, the ability to work independently and determine appropriate courses of action, and capacity to handle multiple priorities are essential. Excellent written and verbal communication skills are required, along with a passion for improving consumer experiences. Preferred qualifications include a minimum of one year of experience reading and interpreting claims, and experience with systems such as CAS, MTV, CISpro, and CIS. A Bachelor's Degree, experience in financial recovery, knowledge of Microsoft Access and Project, and experience in a fast-paced, metric-driven operational setting are also preferred.

Responsibilities

The Payment Integrity Professional 2 will utilize technology and data mining to detect anomalies, identify, and collect overpayments on claims. They will contribute to investigations of fraud and waste, and support financial recovery efforts. This role involves interpreting data to determine appropriate courses of action and contributing to cost reduction by increasing the accuracy of provider contract payments and ensuring correct claims payment. Team meetings may require occasional travel to Louisville, and while the position is remote, occasional travel for training or meetings may be required.

Skills

Microsoft Office Suite

Excel

PowerPoint

Word

Data Mining

Claims Interpretation

Attention to Detail

Independent Work

Prioritization

Confidentiality

Communication Skills

Problem-Solving

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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