Humana

Sr Clinical Compliance Prof. RCM & Coding Auditor

San Antonio, Texas, United States

Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, Managed Care, Health ServicesIndustries

Senior Clinical Compliance Professional

Employment Type: Full time

Position Overview

CenterWell Senior Primary Care (PCO) is seeking a Senior Clinical Compliance Professional to join its growing Regulatory Compliance team. This team is responsible for assessing, investigating, auditing, and validating the mitigation of compliance risks across the organization. The Senior Clinical Compliance Professional will support the Director of Compliance by ensuring adherence to governmental requirements for clinics at both federal and state levels. This role involves in-depth evaluation of variable factors for moderately complex to complex compliance issues.

Responsibilities

  • Develop and/or evaluate compliance policies and procedures.
  • Research compliance issues and recommend changes to ensure compliance with federal and/or state requirements related to Provider Clinic operations, billing, investigations, and processes.
  • Coordinate site visits for regulators.
  • Coordinate the implementation and compliance with corrective action plans, as needed.
  • Participate in all phases of the audit process, including evaluating control design and adequacy, testing for adherence to policies and internal controls, and communicating issues and recommendations to management.
  • Serve as a regulatory compliance subject matter expert within the 2nd line of defense compliance function.
  • Communicate compliance-related requirements to high-level business leaders within the PCO.
  • Assess compliance risks to PCO and leverage these assessments to design auditing and monitoring activities for the workplan.
  • Execute assigned portions of the PCO compliance workplan throughout the year.
  • Conduct compliance-related audits to assess internal controls, examine healthcare records and processes, and analyze and report risks.
  • Influence department strategy by identifying and overseeing the development of continuous monitoring activities.
  • Provide reporting on metrics and M&A activity related to revenue cycle management.

Requirements

  • Bachelor's degree.
  • 3 or more years of healthcare experience in revenue cycle management (related to billing, coding, collections for Medicare and Medicaid claims).
  • Experience with auditing and monitoring of healthcare records.
  • Must be able to work core business hours on EST time between 9 am - 5 pm.
  • Willingness to travel up to 10% to conduct audits at site locations.
  • Ability to manage multiple or competing priorities and meet deadlines.
  • Passion for contributing to an organization focused on continuously improving consumer experiences.
  • Effective verbal and written communication skills.
  • Strong attention to detail.
  • Ability to articulate findings and impacts.
  • Knowledge/understanding of laws and regulations governed by the Department of Insurance and CMS.

Preferred Qualifications

  • Compliance regulations knowledge and compliance auditing experience.
  • Ability to analyze large data sets.
  • Knowledge of healthcare compliance, mainly primary care and risk adjustment; pharmacy knowledge is a plus.
  • Certified Coder (CPC, CRC, and/or CMC).
  • Experience with metrics and reporting.

Company Information

CenterWell Senior Primary Care (PCO) is a growing provider organization that currently operates about 340+ senior-focused primary care centers in 15 states. We are a growing provider organization dedicated to putting health first and fostering a caring community.

Work-At-Home Requirements

To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided inter...

Skills

Healthcare Compliance
Regulatory Auditing
Policy Development
Investigation & Research
Corrective Action Plans
Federal & State Healthcare Regulations
Healthcare Operations
Internal Controls
Regulatory Coordination

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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