Remote Senior Claims Compliance Auditor

Humana; United States; Remote; USD 86,000 - 119,000; Full time

Benefits offered by this job

Remote work within US

Travel opportunities

Job summary

Humana is seeking a Senior Compliance Professional to analyze policies and programs, audit claims delegates, and drive corrective actions to ensure regulatory and Humana standards are met. You will build relationships with internal and external partners and prepare detailed audit reports for management.

You will review delegates' policies and claims files across medical, mental health, and vision, validate coding and documentation, and track corrective actions to ensure timely resolution and

Qualifications

• 2+ years of claims and/or audit experience.
• Knowledge/understanding of claims.
• Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards.
• Ability to travel up to 20% to site delegations.
• Bachelor’s degree.
• Experience with delegation laws, regulations and accreditation requirements (CMS, NCQA).
• Auditing experience including medical, mental health or vision claims.
• Working knowledge of coding standards (ICD, CPT, HCPCS) and validation of coding/billing.
• Experience with audit methodology (sampling, root cause analysis, scorecards).
• Vendor management experience.

Responsibilities

• Perform oversight audits of claims delegates to ensure compliance with regulations and Humana standards.
• Audit medical, mental health and vision claims and drive corrective actions through resolution.
• Review delegates’ policies, procedures, and claims files for accuracy and compliance.
• Issue corrective action plans and monitor implementation to ensure timely resolution.
• Serve as primary contact for assigned claims delegates and maintain relationships.
• Maintain documentation of oversight activities and audit results.
• Use data analysis tools and audit software to monitor trends and support QA.
• Collaborate with claims processors and compliance teams to resolve issues.
• Assist in developing/updating delegated oversight policies and training materials.
• Support readiness for regulatory audits and accreditation surveys.

Skills

Strong communication

Attention to detail

Project coordination

Process improvement

Time management

Influencing/negotiation

Multitasking

Education

Bachelor’s degree

Tools

MS Word

Excel

PowerPoint

Audit software

Job description

Humana is seeking a Senior Compliance Professional to analyze policies and programs, audit claims delegates, and drive corrective actions to ensure regulatory and Humana standards are met. You will build relationships with internal and external partners and prepare detailed audit reports for management.

You will review delegates' policies and claims files across medical, mental health, and vision, validate coding and documentation, and track corrective actions to ensure timely resolution and