Director, Claims Integrity & Payment Optimization

humana; Town of Florida (NY); On-site; USD 139,000 - 191,000; Full time

Job summary

Humana seeks a Director of Claims Processing and Payment Integrity to oversee claims adjudication, audit activity, and fraud detection initiatives. The role leverages data analytics to ensure accurate, timely payments and supports strategic programs across payer systems.

On-site preference in Miramar, FL, with remote options considered. Ideal candidate has 8+ years Medicare/Medicaid claims management experience, strong cross-functional collaboration, and PMP certification.

Qualifications

• Bachelor's Degree, or combination of education and experience to ensure success in the role.
• 8+ years of Medicare/Medicaid claims management experience.
• Ability to determine needed approach, resources, and goals to meet business objectives.
• Experience cross-department collaboration.
• Experience with Plexis and Oracle systems.
• Project Management Professional (PMP) certification.

Responsibilities

• Oversee adjudication of claims and auditing processes.
• Use technology and data mining to detect anomalies in claims.
• Investigate fraud, waste and financial recovery.
• Contribute to cost reduction by improving provider contract payments.

Skills

Leadership

Cross-functional collaboration

Analytical thinking

Communication skills

multitasking

Education

Bachelor's Degree

Master's Degree

Tools

Plexis

Oracle systems

LucidChart or Visio

Job description

Humana seeks a Director of Claims Processing and Payment Integrity to oversee claims adjudication, audit activity, and fraud detection initiatives. The role leverages data analytics to ensure accurate, timely payments and supports strategic programs across payer systems.

On-site preference in Miramar, FL, with remote options considered. Ideal candidate has 8+ years Medicare/Medicaid claims management experience, strong cross-functional collaboration, and PMP certification.