Risk Management Professional

Claims Risk Management Professional

Become a part of our caring community and help us put health first. The Claims Risk Management Professional is responsible for ensuring payment quality of claims in accordance with TRICARE policy requirements. This role involves reviewing pre-payment, high dollar claims to assess payment accuracy and identify potential claim payment risks. The Claims Risk Management Professional is expected to provide accurate, actionable, and thorough feedback by completing high-dollar pre-pay reviews daily. Audit results are shared with operational areas to help mitigate organizational risk and support quality-related goals. The incumbent will regularly exercise discretion and judgment in prioritizing requests, and will interpret and adapt procedures, processes, and techniques while working under limited guidance, leveraging previous experience and organizational knowledge.

Key responsibilities include :

• Utilize strong analytical, technical, and communication skills, as well as a comprehensive understanding of TRICARE policies, to conduct daily high dollar claim quality audit reviews.
• Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues.
• Develop and recommend controls and cost-effective approaches to minimize claims processing risks.
• Perform advanced administrative / operational / customer support duties that require independent initiative and judgment.
• Assist in special projects as directed by Department Management.

Use your skills to make an impact.

Required qualifications :

Preferred qualifications :

Work at home requirements :

Scheduled weekly hours : 40

Pay range : $65,000 - $88,600 per year

This job is eligible for a bonus incentive plan.

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. Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our accessibility resources at https : / / www.humana.com / legal / accessibility-resources?source=Humana_Website.