Senior Medical/Financial Risk Evaluation Professional

Profile

Description

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.

Responsibilities

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.

Additional Responsibilities:


Tracking of progress to goals with recommendations to stakeholders
Analysis and executive level summaries
Documentation and approval authority of audits and communications
Approval of production processes to ensure alignment with objectives
Process implementation to enhance efficiencies and improve outcomes
Proactive communication with internal/external groups as needed for processes and education
Ensure all compliance requirements are met
Quality reviews of refund activity


Required Qualifications


Bachelor's degree or equivalent experience
4 - 5 years or more of technical experience (Executive Level Summary, Relational Databases)
Strong background in Claims (Operational claims knowledge including facility reimbursement methodology), SIU, Audits and Financial Recovery
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Experience with Analysis and Executive Level Summaries
Experience with Financial Recovery Processes
Capability to compile and analyze information from various data streams
Background working with Audits and the approval of production processes
Process implementation to enhance efficiencies and improve outcomes
Experience meeting Compliance Requirements and Quality Reviews of refund activity
Exception verbal and written Communication skills; background working Stakeholders and Internal / External groups
Work shift will be in Eastern Time Zone
Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) is required.
A dedicated home office space, with a locked door, lacking ongoing interruptions to protect member PHI / HIPAA information
Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test


Additional Information

The following policy applies ONLY to associates working in the state of Arizona :

Humana is committed to providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective July 1, 2011, Humana has adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.

Scheduled Weekly Hours

40

Company info

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