Remote Senior Claims Compliance Specialist

Humana; Bismarck (ND); Remoto; USD 86.000 - 119.000; Tempo pieno

Descrizione del lavoro

Humana, Inc. is seeking a Senior Compliance Professional to perform oversight audits of claims delegates, ensuring adherence to state and federal regulations and Humana standards. You will develop relationships with internal and external partners and drive corrective actions to maintain audit readiness.

The role emphasizes data analysis, reporting, and collaboration with compliance teams to propel process improvements and regulatory readiness across the organization.

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 and documentation against regulatory requirements.
• Issue corrective action plans as applicable and monitor implementation until resolution.
• Serve as primary contact for assigned claims delegates, ensuring compliance with contractual and regulatory requirements.
• Develop and maintain key relationships with assigned delegates to optimize business results.
• Maintain detailed documentation of oversight activities, audit results and compliance status for 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 standards.

Conoscenze

Claims knowledge

Audit proficiency

Regulatory understanding

Strong communication

Formazione

Bachelor’s degree

Strumenti

MS Word

Excel

PowerPoint

Descrizione del lavoro

Humana, Inc. is seeking a Senior Compliance Professional to perform oversight audits of claims delegates, ensuring adherence to state and federal regulations and Humana standards. You will develop relationships with internal and external partners and drive corrective actions to maintain audit readiness.

The role emphasizes data analysis, reporting, and collaboration with compliance teams to propel process improvements and regulatory readiness across the organization.