Sr. Claims Compliance Professional

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Be a part of Compliance – Use your business knowledge to help analyze and develop policies, procedures and programs supporting our compliance initiatives. As a Senior Compliance Professional, you will perform oversight audits of our claims delegates to ensure compliance with current state/federal regulations, as well as Humana standards. You will serve as the primary point of contact for assigned claims’ delegates, auditing medical, mental health and vision claims and driving corrective actions through resolution to help keep Humana and our delegates audit ready.

Humana is seeking a Senior Compliance Professional to develop and maintain key relationships by working with internal and external business partners to evaluate and maintain compliance.

Efficiently track, report, and communicate all audit information to delegates and required internal departments. Prepare detailed audit reports and present findings to management and relevant stakeholders.

Review and analyze the delegates’ policies and procedures as well as claims files (medical, mental health and vision) for accuracy, completeness and policy compliance, validating coding, billing practices and documentation, to ensure they are compliant with regulatory and legislative requirements

Issue corrective action plans as applicable. Work with the assigned delegates until the issue has been resolved. Monitor implementation and follow up to ensure timely resolution and sustained compliance.

Serve as the primary point of contact for assigned claims delegates, ensuring compliance with contractual, regulatory and Humana requirements.

Develop and maintain key relationships with the assigned delegates to optimize business results.

Maintain detailed documentation of oversight activities, audit results and compliance status for internal and external reporting.

Use data analysis tools and audit software to monitor trends and support quality assurance.

Assist in special projects that promote department efficiency.

Collaborate with claims processors and compliance teams to resolve issues and improve processes.

Help develop and update delegated oversight policies, procedures and training materials.

Support readiness for regulatory audits and accreditation surveys by ensuring delegates meet all applicable standards.

Knowledge/understanding of claims

Ability to effectively represent Humana, with a high level of professionalism, when working with external delegates

Proficient knowledge of MS Word, Excel and PowerPoint,

Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards

Excellent communication skills, both oral and written, including the ability to present audit findings and influence delegates to resolve deficiencies

Bachelor’s degree

Experience with delegation laws, regulations and accreditation requirements, such as CMS, NCQA and applicable state requirements

Claims auditing experience, including medical, mental health or vision claims

Working knowledge of coding standards (ICD, CPT and HCPCS) and the ability to validate coding, billing and documentation against regulatory requirements

Experience with audit methodology, such as sampling, root cause analysis and scorecards or dashboards

Experience using data analysis or audit tools to monitor trends and support quality assurance