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The Director, Claims Processing and Payment Integrity oversees adjudication of claims and uses technology and data mining to audit claims for accuracy, detect anomalies in data, and identify over and under-payment of claims. Contributes to the accurate and timely processing of claims and investigations of fraud waste and financial recovery. The Director, Claims Processing and Payment Integrity requires an in-depth understanding of TPA business, claims processing, and how organization capabilities interrelate across the function or segment.
The Director, Claims Processing and Payment Integrity contributes to overall provider satisfaction by paying claims accurately and timely, and cost reduction by increasing the accuracy of provider contract payments in our payer systems. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, new business contracts, drives goals and objectives, and improves performance. Provides input into functions strategy.
Use your skills to make an impact
Required Qualifications
- Bachelor's Degree, or combination of education and experience to ensure success in the role
- 8 or more years of Medicare and/or Medicaid claims management experience
- Able to determine the needed approach, resources, and goals to meet business objectives
- Demonstrated experience with cross departmental collaboration
- Experienced facilitating, consulting, and delivering complex concepts
- Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel
- Ability to handle multiple priorities
- Capacity to maintain confidentiality
- Excellent communication skills both written and verbal
- Proficiency in analyzing and interpreting financial trends
- Strong collaboration skills
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Preferred Qualifications
- Master's Degree
- Experience leading projects and processes
- Experience in Financial Recovery
- Experience with Plexis and Oracle systems
- Knowledge of LucidChart or Visio
- Project Management Professional (PMP) Certification
- Bilingual in Spanish and English
- Progressive experience in contracting or claims area for a health solutions industry
Additional Information
Remote considered, but preference is onsite in Miramar, FL.
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.
$138,900 - $191,000 per year
This 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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
