[Remote] Senior Process Improvement Professional at Humana

Kentucky, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

Minimum 2 years of claims processing experience utilizing CAS
Minimum 2 years of experience following claims processing and/or edit documents in Mentor
Experience taking a processed claim and determining what edits/processes the claim hit as well as following the processing guidelines to determine if the claim processed appropriately and if it paid the correct benefits per the members plan and providers contract
Experience utilizing CRM
Proficiency with Microsoft Office Word and Excel including the ability to create pivot tables
Demonstrated experience in root cause analysis and investigation
Strong research skills, with a proven ability to learn quickly and identify improvement opportunities
Comfortable making independent decisions in a dynamic environment
Exceptional attention to detail and accuracy in your work
Ability to switch tasks and adapt priorities as needed
Experience collaborating and communicating effectively with a wide range of stakeholders

Responsibilities

Manages all initial claims processing impacts resulting from Natural Disaster Declarations and Cyber Events, including authorization and referral bypasses, as well as timely filing guideline adjustments
Responsible for mapping all CPT, HCPCS, and Revenue codes to the correct service category in CAS
Conducts feasibility assessments for proposed new benefits
Provides specialized claims processing support for South Carolina, Oklahoma, Michigan, and for the upcoming Georgia Medicaid programs
Reviewing and responding to LRR/Impact Analysis Questionnaires from state agencies and implementing process updates to comply with new regulations under accelerated timelines
Conduct in-depth research on claims, compliance, and legislative requirements to inform process updates and claims payment recommendations

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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