The Code Edit Management Organization has a new Payment Integrity Professional 2 opening available. The Payment Integrity Professional 2 utilizes vendor platforms, claims processing platforms, and data to collaborate with key internal and external business stakeholders, while supporting claims code editing pre and post-implementation and functionality. The opportunity contributes to the overall goal of claims cost reduction and is available for WAH nationwide.
Where you Come In
• Foster relationships between Code Edit Management, internal stakeholders and multiple external code editing vendors
• Support of new code edit reviews, testing, implementation and maintenance management
• Management and resolution of code edit stakeholder inquiries
• Drive process improvements and ensure successful run of business
The Payment Integrity Professional 2 contributes to overall cost reduction, by increasing the accuracy of provider contract payments in our payer systems, and by ensuring correct claims payment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Use your skills to make an impact
WORK STYLE: Remote, work at home. Minimal travel possible: Approximately 1-2x/year for trainings, meetings, conferences.
WORK HOURS: Monday-Friday, 8 hours/day, 5 days/week, in the employee's home time zone. Flexibility will be required to meet business needs.
Required Qualifications
Proficient in managing diverse priorities, adept at swiftly transitioning between tasks based on urgency and demand
Comfortable navigating and making decisions in a dynamic and everchanging environment
Problem-solving abilities, including thinking outside the box and collaborating with others to achieve optimal outcomes
Ability to work both independently and within a team structure, with minimal supervision
Analytical ThinkingProblem-solving abilities, including thinking outside the box and collaborating with others to achieve optimal outcomes
Working knowledge of Microsoft Office Programs Word, SharePoint, and Excel
Strong attention to detail
Proficiency in verbal/written communication
Ability to operate in a fast paced, agile, metric driven operational setting
Commitment to upholding ethical standards and professional integrity in all interactions, including ability to maintain confidentiality
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
STRONGLY PREFERRED: Prior experience utilizing CAS
STRONGLY PREFERRED: Prior experience utilizing code edit vendor tools such as: Rialtic Provider Inquiries Tool, ClaimsXten Web User Interface, Cotiviti What If Tool (WIT), Optum CES Tool, Cotiviti Claims Inquiry Tool (CIT), Nucleus or KnowledgeSource Tool.
Prior experience working with external vendors and/or internal stakeholders
Prior experience with Humana code edit claims processes
Working knowledge of Microsoft Office Programs: PowerPoint and OneNote
Prior experience in THOR Rule creation and/or processes
Prior experience leading projects, and/or processes
Prior experience in Claims Administration and Payment Integrity (CAPI) formerly Claims Cost Management (CCM)
Prior experience analyzing medical claims data
Additional Information
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
Interview Format
As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Hire Vue (formerly Modern Hire) to enhance our hiring and decision-making ability. Hire Vue (formerly Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.
If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone or computer to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.Scheduled Weekly Hours
40Pay 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.
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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.