Senior Payment Integrity Coding Professional

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Health Insurance, HealthcareIndustries

Requirements

Candidates must possess an AAPC or AHIMA Coding Certification and have at least 5 years of experience using coding guidelines by reading and interpreting claims. An exceptional understanding of CMS guidelines, state Medicaid guidelines, correct coding initiatives, national benchmarks, and industry standards is required, along with excellent data analysis skills and experience with SQL, Power BI, and Excel. Strong verbal and written presentation skills are also necessary to communicate complex data clearly.

Responsibilities

The Senior Payment Integrity Coding Professional will contribute to cost reduction by utilizing code editing guidelines and data anomalies to ensure correct claim payment. This role involves in-depth research, cross-departmental collaboration, and independent determination of actions for moderately complex to complex issues. Responsibilities include monitoring and analyzing code edit performance metrics and operational processes to identify inefficiencies, partnering with internal business units to address challenges, and building strong relationships across the enterprise to drive innovation and effective operations. Additionally, the professional will engage in implementations and ad hoc projects, guiding team members on priorities and managing risks and escalations.

Skills

Payment Integrity

Coding Guidelines

Data Analysis

CMS Guidelines

AAPC Certification

AHIMA Certification

Claims Analysis

Process Improvement

Risk Management

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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