Remote Senior Claims Compliance Auditor

African American Talent; Santa Fe (NM); Remoto; USD 86.000 - 119.000; Tempo pieno

Descrizione del lavoro

Humana seeks a Senior Compliance Professional to lead oversight audits of delegated claims activities, ensuring alignment with state and federal regulations and Humana standards. You will partner with internal and external stakeholders to evaluate policies, validate coding and billing, develop corrective action plans, and monitor completion until sustained compliance.

The role supports regulatory readiness and requires up to 20% travel; it is fully remote within the US with occasional onsite

Competenze

• 2+ years of claims and/or audit experience.
• Knowledge/understanding of claims.
• Demonstrated proficiency in MS Word, Excel and PowerPoint.
• Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards.
• Ability to travel up to 20% to site delegations.

Mansioni

• Efficiently track, report, and communicate all audit information to delegates and required internal departments.
• Prepare detailed audit reports and present findings to management and relevant stakeholders.
• Review and analyze the delegates’ policies and procedures as well as claims files (medical, mental health and vision) for accuracy, completeness and policy compliance, validating coding, billing practices and documentation, to ensure they are compliant with regulatory and legislative requirements.
• Issue corrective action plans as applicable. Work with the assigned delegates until the issue has been resolved.
• Monitor implementation and follow up to ensure timely resolution and sustained compliance.
• Serve as the primary point of contact for assigned claims delegates, ensuring compliance with contractual, regulatory and Humana requirements.
• Develop and maintain key relationships with the assigned delegates to optimize business results.
• Maintain detailed documentation of oversight activities, audit results and compliance status for internal and external reporting.
• Use data analysis tools and audit software to monitor trends and support quality assurance.
• Assist in special projects that promote department efficiency.
• Collaborate with claims processors and compliance teams to resolve issues and improve processes.
• Help develop and update delegated oversight policies, procedures and training materials.
• Support readiness for regulatory audits and accreditation surveys by ensuring delegates meet all applicable standards.

Conoscenze

Claims/audit experience

Regulatory knowledge

Communication skills

Attention to detail

Time management

Formazione

Bachelor's degree

Strumenti

MS Word

Excel

PowerPoint

Descrizione del lavoro

Humana seeks a Senior Compliance Professional to lead oversight audits of delegated claims activities, ensuring alignment with state and federal regulations and Humana standards. You will partner with internal and external stakeholders to evaluate policies, validate coding and billing, develop corrective action plans, and monitor completion until sustained compliance.

The role supports regulatory readiness and requires up to 20% travel; it is fully remote within the US with occasional onsite