Become a part of our caring community and help us put health first

The Claims Risk Management Professional is responsible for ensuring payment quality of claims in accordance with TRICARE policy requirements. This role involves reviewing pre-payment, high dollar claims to assess payment accuracy and identify potential claim payment risks. The Claims Risk Management Professional is expected to provide accurate, actionable, and thorough feedback by completing high-dollar pre-pay reviews daily. Audit results are shared with operational areas to help mitigate organizational risk and support quality-related goals. The incumbent will regularly exercise discretion and judgment in prioritizing requests, and will interpret and adapt procedures, processes, and techniques while working under limited guidance, leveraging previous experience and organizational knowledge.

KEY ACCOUNTABILITIES

• Utilize strong analytical, technical, and communication skills, as well as a comprehensive understanding of TRICARE policies, to conduct daily high dollar claim quality audit reviews. Responsibilities include making approval and processing determinations for payment release, conducting focused claim studies, and performing duplicate claim detection through the DHA Duplicate Claims System (DCS).

• Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues. These activities support the mitigation of financial risk and help ensure quality standards are met for quarterly and annual government audits. This process is conducted in accordance with organizational procedures for claims risk management and supports compliance with TRICARE policy requirements.

• Develop and recommend controls and cost-effective approaches to minimize claims processing risks.

• Will perform advanced administrative/operational/customer support duties that require independent initiative and judgment.

• Assist in special projects as directed by Department Management.

Use your skills to make an impact

Required Qualifications

• Our Department of Defense contract requires U.S. Citizenship

• Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services)

• HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.

• 2 years TRICARE claims experience to include professional and institutional claims reimbursement

• Strong knowledge of TRICARE policy and claims processing

Preferred Qualifications

• Bachelor’s degree

Work at Home Requirements

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

• Satellite, cellular and microwave connection can be used only if approved by leadership

• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.

• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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.

$65,000 - $88,600 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, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

Humana Inc. (NYSE: HUM) is committed to putting health first – for our teammates, our customers and our company. Through our Humana insurance services and 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, Medicaid, families, individuals, military service personnel, and communities at large.

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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.