Payment Integrity Professional 2 -- REMOTE Anywhere in US

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Job Information
Humana
Payment Integrity Professional 2 -- REMOTE (Anywhere in US)
in
Boston
Massachusetts
Description
The Payment Integrity Professional 2 uses technology and data mining, detects anomalies in data to identify and collect overpayment of claims. Contributes to the investigations of fraud waste and our financial recovery. The Payment Integrity Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
Responsibilities
The Payment Integrity Professional 2 contributes to overall cost reduction, by increasing the accuracy of provider contract payments in our payer systems, and by ensuring correct claims payment in a Prepayment Auditing environment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Primary Responsibilities
Collaborate with Audit associates, leaders and managers as well as internal Humana partners
Proactively research and determine root cause analysis and make recommendations
Facilitates discovery of new opportunities for program growth and support ongoing program performance
Coordinates and conducts thorough research of clinical and SIU data validation within THOR system compared to Legacy
Support data interpretation for process enhancements, performance, efficiency and determining process gaps
Required Qualifications
1 years' work experience processing, reading and interpreting claims on CAS and/or MTV
Experience in CCM
Experience with data analysis/analytics
Proficient in Microsoft Office Programs Word, PowerPoint, and Excel
Strong attention to detail
Ability to work independently and determine appropriate courses of action
Ability to handle multiple priorities
Capacity to maintain confidentiality
Excellent written and verbal communication skills
Experience in a fast paced, metric driven, operational setting
Preferred Qualifications
Bachelor's Degree or higher
Experience leading people, projects, and/or processes
Experience with data reviews, making determinations and presenting results/solutions
Experience using the following systems: CISpro and CIS
Knowledge of Microsoft Programs: EDW, SQL, Access and Project
Work at Home/Remote Requirements
Must ensure designated work area is free from distractions during work hours and virtual meetings
Must provide a high-speed DSL or cable modem for a workspace (Satellite, wireless and Hotspots are prohibited). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) for optimal performance of is required
COVID Vaccination Policy:
For this job, associates are required to be fully COVID vaccinated, including booster or undergo weekly COVID testing and wear a face covering while at work. The weekly testing will need to be done through an approved Humana vendor, and unvaccinated associates should follow all social distancing and masking protocols if they are required to come into a Humana facility or work outside of their home.
If progressed to offer, you will be required to:
Provide proof of full vaccination, including booster, or commit to testing protocols OR  
Provide proof of applicable exemption including any required supporting documentation
Medical, religious, state and remote-only work exemptions are available.
Scheduled Weekly Hours
40

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