Senior Claims Compliance Lead - Remote

Humana, Inc.; Louisville (KY); A distancia; USD 86.000 - 119.000; Jornada completa

Descripción de la vacante

Humana, Inc. is seeking a Senior Compliance Professional to analyze and oversee delegated claims audits across medical, mental health and vision categories. You will develop corrective actions, monitor implementation, and maintain audit-ready documentation with internal and external stakeholders.

You will build relationships with internal partners, assess policies, and use audit tools to identify trends. Travel up to 20% is possible, and the role supports regulatory readiness and policy

Formación

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

Responsabilidades

• Perform oversight audits of claims delegates to ensure compliance with state/federal regulations and Humana standards.
• Serve as the primary contact for assigned claims delegates; audit medical, mental health and vision claims and drive corrective actions to resolution.
• Review delegates’ policies and procedures and claims files for accuracy, completeness and policy compliance; validate coding, billing and documentation.
• Issue corrective action plans and monitor implementation until timely resolution; ensure sustained compliance.
• Maintain documentation of oversight activities, audit results and compliance status for internal/external reporting.
• Use data analysis tools and audit software to monitor trends and support quality assurance.
• Collaborate with claims processors and compliance teams to resolve issues and improve processes.
• Assist in developing/updating delegated oversight policies, procedures and training materials.
• Support readiness for regulatory audits and accreditation surveys by ensuring delegates meet applicable standards.

Conocimientos

Claims knowledge

Audit experience

Process improvement

Communication skills

Regulatory compliance

Educación

Bachelor's degree

Herramientas

MS Word

MS Excel

MS PowerPoint

Descripción del empleo

Humana, Inc. is seeking a Senior Compliance Professional to analyze and oversee delegated claims audits across medical, mental health and vision categories. You will develop corrective actions, monitor implementation, and maintain audit-ready documentation with internal and external stakeholders.

You will build relationships with internal partners, assess policies, and use audit tools to identify trends. Travel up to 20% is possible, and the role supports regulatory readiness and policy