Senior Medical and Financial Risk Evaluation Professional

Senior Medical / Financial Risk Evaluation Professional

Become a part of our caring community and help us put health first. The Senior Medical / Financial Risk Evaluation Professional is responsible for supporting the development, implementation, and monitoring of medical / financial risk. The Senior Medical / Financial Risk Evaluation 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 Medical / Financial Risk Evaluation Professional identifies, assesses, and mitigates any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events. Maintains a balance between risk mitigation and efficiency. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Perform routine quality audits on PPI data mining partner concepts to determine payment accuracy, giving immediate feedback to assigned partner(s) as needed. Act as a liaison between internal areas and our PPI business partners. Lead business partner conference calls and meetings. Provide training when needed for PPI data mining business partners. Report / resolve security and system issues for external vendors. Monitor partner quality and provide ad hoc reports as needed. Identify data trends, develop solutions to improve processes, and assist with presenting and implementing recommendations and solutions. Lead or participate in cross-functional projects.

Required Qualifications

Bachelors Degree. Minimum of 3 years of medical claims auditing experience (interpreting if claims initially paid correctly in the system). Minimum of 2 years Provider Payment Integrity (formally known as Financial Recovery) experience. CAS claims knowledge. Prior vendor relationship experience / knowledge. Intermediate knowledge with Microsoft Excel and Power Point. Ability to confidently communicate verbally and via email with external vendor partners. Demonstrated strong emotional intelligence. Strong relationship building skills. Ability to self-start and prioritize on assignments given / research oriented. Experience with cross-functional project management, including summarization of project status, and presentation to leadership. Must be passionate about contributing to an organization focused on continuously improving consumer experiences.

Preferred Qualifications

Knowledge of or the ability to gather knowledge on Medicare Advantage and Medicaid State Regulations. Certified Professional Coding (AAPC). Previous experience working with the internal PPI peer teams (Code Edit, Prepay, CCRO, Missed Opportunities, etc.). Experience with provider contracts, understanding intent and possible load issues for claims payment impact.

Additional Information

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue 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. To ensure Home or Hybrid Home / Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home / Office employees must meet the following criteria : At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connection can be used only if approved by leadership. Employees 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 employees 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. Travel : While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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.

$86,300 - $118,700 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline : 12-14-2025

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.

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.