Claims Risk Management Professional

Employment Type: Full-time

Position Overview

Become a part of our caring community and help us put health first. The Claims Risk Management Professional is responsible for ensuring payment quality of claims in accordance with TRICARE policy requirements. This role involves reviewing pre-payment, high dollar claims to assess payment accuracy and identify potential claim payment risks. The Claims Risk Management Professional is expected to provide accurate, actionable, and thorough feedback by completing high-dollar pre-pay reviews daily. Audit results are shared with operational areas to help mitigate organizational risk and support quality-related goals. The incumbent will regularly exercise discretion and judgment in prioritizing requests, and will interpret and adapt procedures, processes, and techniques while working under limited guidance, leveraging previous experience and organizational knowledge.

Key Accountabilities

• Utilize strong analytical, technical, and communication skills, as well as a comprehensive understanding of TRICARE policies, to conduct daily high dollar claim quality audit reviews.
• Responsibilities include making approval and processing determinations for payment release, conducting focused claim studies, and performing duplicate claim detection through the DHA Duplicate Claims System (DCS).
• Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues. These activities support the mitigation of financial risk and help ensure quality standards are met for quarterly and annual government audits.
• This process is conducted in accordance with organizational procedures for claims risk management and supports compliance with TRICARE policy requirements.
• Develop and recommend controls and cost-effective approaches to minimize claims processing risks.
• Perform advanced administrative/operational/customer support duties that require independent initiative and judgment.
• Assist in special projects as directed by Department Management.

Use your skills to make an impact.

Requirements

• Required Qualifications:
  • Our Department of Defense contract requires U.S. Citizenship.
  • Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services).
  • HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
  • 2 years TRICARE claims experience to include professional and institutional claims reimbursement.
  • Strong knowledge of TRICARE policy and claims processing.
• Preferred Qualifications:
  • Bachelor’s degree.

Work at Home Requirements

• 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.
• 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.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• 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.

Compensation

• Scheduled Weekly Hours: 40
• Pay Range: $65,000 - $88,600 per year
  • The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
• This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Company Information

Humana, Inc. and its aff...