[Remote] Senior Payment Integrity Professional at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

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 (ie 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
Ability to meet the internet speed requirements (download speed of 25 Mbps and an upload speed of 10 Mbps)

Responsibilities

Uses technology and data mining to detect anomalies in data to identify and collect overpayment of claims
Contributes to the investigations of fraud, waste, and financial recovery
Works on moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors
Contributes to overall cost reduction by increasing the accuracy of provider contract payments in payer systems
Ensures correct claims payment
Influences department’s strategy
Makes decisions on moderately complex to complex issues regarding technical approach for project components
Exercises considerable latitude in determining objectives and approaches to assignments
Manages and makes decisions on moderately complex to complex technical issues and projects
Collaborates with cross-functional teams to achieve departmental goals

Skills

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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