Senior Risk Management Professional - Humana
Columbia, SC
About the Job
Become a part of our caring community and help us put health first
The Senior Risk Management Professional identifies and analyzes potential sources of loss to minimize risk. The Senior Risk Management Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
The Senior Claims Risk Management Professional will ensure claims payment quality in relation to our TRICARE policy requirements. The Senior Claims Risk Management Professional will investigate claims to identify errors and potential claim payment risks. They are expected to provide accurate, actionable and thorough feedback by completing quality audit reviews on a daily basis. Quality audit results are provided to operational areas to mitigate risk to the organization and further support quality related goals. The Senior Claims Risk Management Professional will regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and are expected to work under limited guidance due to previous experience and depth of knowledge of administrative processes and organizational knowledge.
KEY ACCOUNTABILITIES
+ 70% -- This individual utilizes strong analytics, technical, and communication skills as well as deep, broad understanding of TRICARE policies to complete high dollar claim quality audit reviews, which consist of approval and processing determinations for release of payment. This individual is responsible for conducting focus claim studies and duplicating claim detection through the DHA Duplicate Claims System (DCS).
+ 15% -- This individual researches alleged claim payment errors for quarterly and annual government audits. Where appropriate, this individual prepares written rebuttal responses to alleged payment errors using exhibits and TRICARE Policy references as support.
+ 5% -- This individual develops and recommends controls and cost-effective approaches to minimize claims processing risks
+ 5% -- This individual will perform advanced administrative/operational/customer support duties that require independent initiative and judgment
+ 5% -- This individual assists in special projects as directed by Department Management
Use your skills to make an impact
Required Qualifications
+ Our Department of Defense contract requires U.S. citizenship
+ Successfully receive approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
+ Minimum 2 years of experience in TRICARE claims experience to include professional and institutional claims reimbursement
+ Self-starter and able to succeed with minimal supervision or direct managerial oversight
+ Strong analytical and decision making skills
+ Familiarity with mainframe and personal computer applications
+ Ability to work within deadlines, demonstrate independence and be able to self-manage in a production environment
+ Comprehensive knowledge of Microsoft Office Applications including Word, Excel, and Access
+ Excellent verbal communication skills
Work-At-Home Requirements
+ At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
+ Satellite, cellular and microwave connection can be used only if approved by leadership
+ Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
+ Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
+ Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
+ Bachelor's degree in accounting, business, or information systems, with significant accounting concentration
+ Experience with statistical analytic software packages such as SAS, Tableau and/or other data presentation and analytical tools
Additional Information
+ As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
+ If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. This is a remote role - #LI-Remote
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$76,800 - $105,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
The Senior Risk Management Professional identifies and analyzes potential sources of loss to minimize risk. The Senior Risk Management Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
The Senior Claims Risk Management Professional will ensure claims payment quality in relation to our TRICARE policy requirements. The Senior Claims Risk Management Professional will investigate claims to identify errors and potential claim payment risks. They are expected to provide accurate, actionable and thorough feedback by completing quality audit reviews on a daily basis. Quality audit results are provided to operational areas to mitigate risk to the organization and further support quality related goals. The Senior Claims Risk Management Professional will regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and are expected to work under limited guidance due to previous experience and depth of knowledge of administrative processes and organizational knowledge.
KEY ACCOUNTABILITIES
+ 70% -- This individual utilizes strong analytics, technical, and communication skills as well as deep, broad understanding of TRICARE policies to complete high dollar claim quality audit reviews, which consist of approval and processing determinations for release of payment. This individual is responsible for conducting focus claim studies and duplicating claim detection through the DHA Duplicate Claims System (DCS).
+ 15% -- This individual researches alleged claim payment errors for quarterly and annual government audits. Where appropriate, this individual prepares written rebuttal responses to alleged payment errors using exhibits and TRICARE Policy references as support.
+ 5% -- This individual develops and recommends controls and cost-effective approaches to minimize claims processing risks
+ 5% -- This individual will perform advanced administrative/operational/customer support duties that require independent initiative and judgment
+ 5% -- This individual assists in special projects as directed by Department Management
Use your skills to make an impact
Required Qualifications
+ Our Department of Defense contract requires U.S. citizenship
+ Successfully receive approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
+ Minimum 2 years of experience in TRICARE claims experience to include professional and institutional claims reimbursement
+ Self-starter and able to succeed with minimal supervision or direct managerial oversight
+ Strong analytical and decision making skills
+ Familiarity with mainframe and personal computer applications
+ Ability to work within deadlines, demonstrate independence and be able to self-manage in a production environment
+ Comprehensive knowledge of Microsoft Office Applications including Word, Excel, and Access
+ Excellent verbal communication skills
Work-At-Home Requirements
+ At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
+ Satellite, cellular and microwave connection can be used only if approved by leadership
+ Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
+ Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
+ Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
+ Bachelor's degree in accounting, business, or information systems, with significant accounting concentration
+ Experience with statistical analytic software packages such as SAS, Tableau and/or other data presentation and analytical tools
Additional Information
+ As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
+ If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews. This is a remote role - #LI-Remote
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$76,800 - $105,800 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, 'Humana') offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Source : Humana