Manager Fraud amp Waste Licensed RN Remote US

Profile

Description

Humana's Claims Cost Management (CCM) organization is seeking a Manager, Fraud & Waste to join the Provider Payment Integrity-Clinical Audit team working remote anywhere in the US. As the Fraud & Waste Manager at Humana, you will support our efforts for ensuring claims payment accuracy, so that our members receive quality healthcare at an affordable price. You will lead a team of professionals skilled in conducting prepayment and post payment reviews to detect, prevent, and correct fraud, waste, and abuse.

Responsibilities

that are identified during review. The ideal candidate for this role is a registered nurse with prior auditing experience, proven leadership ability, and experience in managing multiple and competing priorities.

Core Responsibilities


Lead a team of 15 FTEs in the day to day work of reviewing claims payments for clinical/coding accuracy
Assist with reporting clinical findings and recommendations
Identify and suggest process improvement opportunities
Develop and monitor team goals, provide ongoing feedback and coaching, and conduct annual performance reviews
Facilitate cross collaboration with internal resources to promote team work and empowerment to make informed decisions


Required Qualifications


Bachelor's Degree in health or business related field or equivalent years of experience in a similar role will be accepted in lieu of a degree
Active Registered Nurse (RN) license
3 years of healthcare experience within a fraud investigations or auditing role
2 years of direct/indirect leadership and/or progressive business consulting experience
Prior experience with medical coding as well as solid knowledge of healthcare payment methodologies
Prior experience leading meetings and presenting material to broad audiences


Work at Home Requirements


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 for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information


Preferred Qualifications


Certified Professional Coder (CPC) strongly preferred
Familiarity with CMS and Humana regulatory policies
Prior health insurance claims experience
Prior experience managing Financial Recovery
Prior experience working within a fast paced, metric driven operational setting
Claims inventory management


Scheduled Weekly Hours

40

Colorado Pay Range

The compensation range represents a good-faith estimate of annualized starting pay at the time of posting based on a full-time 40-hour workweek and may vary based on geographic location and/or employment type. Individual pay decisions will vary based on demonstrated job-related skills such as education, experience, certifications, etc.

82,500-113,475

Pay Type

Salary

Incentive

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.

Company info

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