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

This is a unique opportunity to help lead and transform the care and experience that we provide for members, providers and caregivers - working to meet their financial, social, emotional and medical needs - and help shape the necessary tech-enabled services to deliver on that experience. As a key member of the Edge Operations team, you will have the chance to bring your bright ideas and energy to work every day to improve the lives and health of the members we serve. We are looking for a person who is willing to jump in and help build this business from the ground up, contributing wherever assistance is needed.

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. The Senior Medical/Financial Risk Evaluation Professional will identify opportunities for appropriate claims adjudication based on benefit payment, contract interpretation, and compliance with policies and procedures. The Senior Medical/Financial Risk Evaluation Professional works on problems of diverse scope and complexity ranging from moderate to substantial. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision, uses independent judgment requiring analysis of variable factors and determining the best course of action.


Develop and create processes to ensure first time accurate adjudication of claims and payments for members and providers.
Working with Edge leadership, develop new, or change existing program deliveries to support trend opportunities or business needs. Includes design to delivery, with consumer experience in mind; documenting and delivering all details of staffing needs, process flow, system needs, data needs, etc. Will necessitate understanding of all Edge operational systems.
Work as liaison with other Humana Core Areas to eliminate provider/member abrasion and duplicate efforts
Develop new processes where the team currently lacks expertise, example: work with vendors and other technology leaders to develop effective use of operational systems, standardize processes and working with other operational leaders to develop KPIs and monitoring capabilities.
Assist in evaluating and implementing new technologies
Lead business system support team that works inquiries and escalations from operational teams
Identify new concepts for accurate billing/payment
Research industry Clinical/Coding updates/guidelines/policies
Assist with Provider and Escalated Inquiries


Required Qualifications


Must be passionate about contributing to an organization focused on continuously improving consumer experiences
5 or more years of claims experience in healthcare and/or health insurance industry
Knowledge of claims pricing/reimbursement, claims and systems
Ability to define and track KPIs and other measurable success criteria
Demonstrated ability to get things done in a rapidly changing environment
Demonstrated ability to influence decision making in different contexts
Demonstrated ability to multitask and prioritize projects
Ability to break down complex problems into actionable steps
Ability to facilitate collaborative decision-making in a workshop context
Excellent verbal and written communication skills and ability to adapt your communication style for the audience
Proficient with MS Office (Word and Excel)
Possess self-drive and strong initiative


Preferred Qualifications


Bachelor's degree
Experience in managed care or health care administration
Working and/or certification in medical terminology, ICD-9/10, HCPCS, DRG, and APC pricing


Additional Information

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called Montage SMS Text/Voice Messaging to enhance our hiring and decision-making ability. Montage SMS Text/Voice Messaging 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. This process may also require audio and/or video capabilities at various times throughout the interview and selection process.

Important Information Regarding COVID-19

In order to support the CDC recommendations on social distancing and reduce health risks for associates, members and public health, Humana is deploying virtual and video technologies for all hiring activities. This position may be subject to temporary work at home requirements for an indefinite period.

Necessary equipment and devices are provided however, associates must have a minimum internet connection speed of 10m x 1m, and a dedicated secure home workspace for interview or work purposes. Humana continues to monitor the situation and will adjust service levels as the coronavirus situation evolves. The changes are temporary and will be evaluated frequently with the goal of returning to normal operations as soon as possible. Your Talent Acquisition representative will advise on the latest recommendations to protect your health and well-being during the hiring process.

#ThriveTogether #WorkAtHome

Scheduled Weekly Hours

40

Company info

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