Director of Claims Processing and Payment Integrity

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

Benefits offered by this job

Bonus incentive plan

Job summary

OneHome, Miramar, FL, seeks a Director, Claims Processing and Payment Integrity to oversee adjudication of claims and apply data mining to audit claims for accuracy, detect anomalies, and identify over- or under-payment. The role requires deep Medicare/Medicaid claims experience and cross-functional leadership to advance payment integrity across payer systems.

The candidate will drive strategic programs, improve provider satisfaction, and lead initiatives to reduce cost while ensuring timely and

Qualifications

• Bachelor's degree or higher required; extensive Medicare/Medicaid claims experience preferred.
• At least 8 years in claims management with a focus on payment integrity.
• Ability to collaborate across departments and drive initiatives.
• Strong communication, confidentiality, and analytical skills.

Responsibilities

• Oversee adjudication of claims and payments.
• Audit claims for accuracy using data analytics.
• Detect anomalies and investigate potential fraud, waste, and financial recovery.
• Lead large-scale programs and improve provider contract payment accuracy.

Skills

Bachelor's Degree

Medicare/Medicaid claims management

Cross-department collaboration

Communication skills

Financial trend analysis

Confidentiality

Provider payment accuracy

Education

Bachelor's Degree

Master's Degree

Tools

Microsoft Office

Excel

Plexis

Oracle

Lucidchart

Visio

Job description

Become a part of our caring community
The Director, Claims Processing and Payment Integrity oversees adjudication of claims and uses technology and data mining to audit claims for accuracy, detect anomalies in data, and identify over and under-payment of claims. Contributes to the accurate and timely processing of claims and investigations of fraud waste and financial recovery. The Director, Claims Processing and Payment Integrity requires an in-depth understanding of TPA business, claims processing, and how organization capabilities interrelate across the function or segment.

Become a part of our caring community
The Director, Claims Processing and Payment Integrity oversees adjudication of claims and uses technology and data mining to audit claims for accuracy, detect anomalies in data, and identify over and under-payment of claims. Contributes to the accurate and timely processing of claims and investigations of fraud waste and financial recovery. The Director, Claims Processing and Payment Integrity requires an in-depth understanding of TPA business, claims processing, and how organization capabilities interrelate across the function or segment.
The Director, Claims Processing and Payment Integrity contributes to overall provider satisfaction by paying claims accurately and timely, and cost reduction by increasing the accuracy of provider contract payments in our payer systems. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes, and implements strategic plans, new business contracts, drives goals and objectives, and improves performance. Provides input into functions strategy.
Required Qualifications
Use your skills to make an impact

• Bachelor's Degree, or combination of education and experience to ensure success in the role
• 8 or more years of Medicare and/or Medicaid claims management experience
• Able to determine the needed approach, resources, and goals to meet business objectives
• Demonstrated experience with cross departmental collaboration
• Experienced facilitating, consulting, and delivering complex concepts
• Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel
• Ability to handle multiple priorities
• Capacity to maintain confidentiality
• Excellent communication skills both written and verbal
• Proficiency in analyzing and interpreting financial trends
• Strong collaboration skills
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

• Master's Degree
• Experience leading projects and processes
• Experience in Financial Recovery
• Experience with Plexis and Oracle systems
• Knowledge of LucidChart or Visio
• Project Management Professional (PMP) Certification
• Bilingual in Spanish and English
• Progressive experience in contracting or claims area for a health solutions industry

Additional Information
Remote considered, but preference is onsite in Miramar, FL.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$138,900 - $191,000 per year
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, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.About Us
About OneHome: OneHome coordinates a full range of post-acute care ranging from home health, infusion therapy and durable medical equipment services at patients’ homes. OneHome’s patient focused model creates one integrated point of accountability that coordinates with physicians, hospitals and health plans serving more than one million health plan members nationwide. OneHome was acquired by Humana in 2021 to advance value-based care. Our culture is inclusive, diverse, and above all, caring. It is important to us that our employees are engaged, supported and fairly treated. We offer a comprehensive benefits package to ensure the health and financial well-being of you and your family.
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.