[Remote] Senior Payment Integrity Professional at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Bachelor’s degree in Business, Finance, Healthcare Administration, Data Analytics, or a related field, or equivalent work experience
Demonstrated experience in claims analysis, payment integrity, or healthcare data analytics, preferably within a managed care or payer environment
Advanced proficiency in data mining tools (e.g., Power BI) and techniques for detecting overpayments
Strong analytical and critical thinking skills; ability to evaluate complex data and variable factors to draw in-depth conclusions
Ability to work independently with minimal direction, exercising sound judgment and considerable latitude in determining approaches to assignments
Proven ability to manage and make decisions on moderately complex to complex technical issues and projects
Effective communication and interpersonal skills, including the ability to influence departmental strategy and collaborate with cross-functional teams
Preferred Qualifications
Master’s degree in a related field
Experience leading people, projects, and/or processes
Experience using the following systems: CAS, CISpro, and CIS
Experience with provider contract payment analysis and knowledge of payer systems
Knowledge of relevant regulatory requirements and industry best practices in claims payment integrity
Familiarity with audit processes and recovery operations in a payer environment
Experience in a fast-paced, metric-driven operational setting

Responsibilities

Uses technology and data mining to detect anomalies in data to identify and collect overpayments of claims
Contributes to the investigations of fraud, waste, and financial recovery
Analyzes moderately complex to complex issues requiring in-depth evaluation of variable factors
Contributes to overall cost reduction by increasing the accuracy of provider contract payments in payer systems and ensuring correct claims payment
Begins to influence department’s strategy
Makes decisions on moderately complex to complex issues regarding technical approach for project components, with work performed without direction
Exercises considerable latitude in determining objectives and approaches to assignments

Skills

Key technologies and capabilities for this role

claims analysispayment integrityhealthcare data analyticsdata miningPower BIanalytical skillscritical thinking

Questions & Answers

Common questions about this position

What qualifications are required for the Senior Payment Integrity Professional role?

A Bachelor’s degree in Business, Finance, Healthcare Administration, Data Analytics, or a related field (or equivalent work experience) is required, along with demonstrated experience in claims analysis, payment integrity, or healthcare data analytics, preferably in a managed care or payer environment.

Is this position remote or hybrid?

The role supports Home or Hybrid Home/Office arrangements, with self-provided internet service required to meet specific criteria for effective work.

What technical skills are needed for this job?

Advanced proficiency in data mining tools like Power BI and techniques for detecting overpayments is required, along with strong analytical and critical thinking skills.

What is the salary or compensation for this position?

This information is not specified in the job description.

What makes a strong candidate for this role?

Candidates with a Master’s degree, experience leading projects or people, familiarity with systems like CAS, CISpro and CIS, and knowledge of payer systems and regulatory requirements stand out.

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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