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DescriptionThe Senior Claims Process & Policy Professional processes new insurance policies, modifications to existing policies, and claims forms. The Senior Claims Process & Policy Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.ResponsibilitiesThis is an office based position in Tampa, FL. The hours are Mon-Fri, 8am-5pm est.The Senior Claims Process & Policy Professional needs to be a strong team player that flexibly and proactively supports consulting engagements. Our team delivers programs that result in high levels of client confidence while maintaining cost efficiency and consumer oriented solutions.
Part C Reporting for Claims Organizational Determinations following CMS protocols and participate in data validation audits;
Oversight of SOX key controls and SOX internal audits;
Review, research and update Claims Policies and Procedures based on CMS Medicare manuals;
Maintain and update process flows and CMS Compliance related documents (letters, EOBs, IDNs);
Support CMS Claims and direct member reimbursement program audits, HEDIS audits and documentation, and HIPAA Privacy and PHI initiatives;
Maintain CARCs and RARCs for claims adjustment codes;
Participate in Compliance related workgroups and projects;
Required Qualifications
Associate's degree
Project Management or Process Improvement experience
Strong data analysis skills
Outstanding oral, written and organizational skills
Excels in a team environment - Must be a “Proactive” team player
Intermediate with MS Excel and PowerPoint
Healthcare experience
Knowledge of CMS Medicare manuals for research and reporting criteria and audit protocols
Preferred Qualifications
Bachelor’s, MBA, CPA or advanced degree in healthcare
PMP certification
Six Sigma GB or BB experience
Proficient with MS Access, Visio and MS Project
Additional InformationAs part of our hiring process for this opportunity, we will be using a technology called Montage Voice which allows us to quickly connect and gain valuable information from you about your relevant experience.If you are selected for a phone screen you will receive an email inviting you to participate in a Montage Voice interview. During this call you will be asked a set of questions pertaining to this particular role and you will provide recorded responses. The entire process takes about 15-20 minutes and can be done at your convenience. Your responses will be reviewed and you will be informed if you were selected for an in person or video interview, depending on your location.Scheduled Weekly Hours40About UsMission: At Humana, our cultural foundation is aligned to helping members achieve their best health by delivering personalized, simplified, whole-person healthcare experiences. Recognizing healthcare needs continue to evolve for each person, for each family and for each community, Humana continuously creates innovative solutions and resources that help people live their healthiest lives on their terms –when and where they need it. Our employees are at the heart of making this happen and that’s why we are dedicated to building an organization of dynamic talent whose experience and passion center on putting the customer first. Equal Opportunity EmployerIt is our policy to recruit, hire, train, and promote people without regard to race, color, religion, sex, national origin, age, sexual orientation, gender identity or expression, disability, or veteran status, except where age, sex, or physical status is a bona fide occupational qualification. View the EEO is the Law poster.If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, or are limited in the ability or unable to access or use this online application process and need an alternative method for applying, you may contact mailboxtasrecruit@humana.com for assistance.Humana Safety and SecurityHumana will never ask, nor require a candidate provide money for work equipment and network access during the application process. If you become aware of any instances where you as a candidate are asked to provide information and do not believe it is a legitimate request from Humana or affiliate, please contact mailboxtasrecruit@humana.com to validate the request.
