Senior Medical/Financial Risk Evaluation Professional

Profile

Description

The Senior Medical/Financial Risk Evaluation Professional is responsible for supporting the development, implementation and monitoring of medical/financial risk. The Senior Medical/Financial Risk Evaluation Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Medical / Financial Risk Evaluation Professional identifies, assesses, and mitigates any medical or financial risk that arises from inadequate or failed processes, people, systems, or external events. Maintains a balance between risk mitigation and efficiency. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

Additional Responsibilities:

Tracking of progress to goals with recommendations to stakeholders

Analysis and executive level summaries

Documentation and approval authority of audits and communications

Approval of production processes to ensure alignment with objectives

Process implementation to enhance efficiencies and improve outcomes

Proactive communication with internal/external groups as needed for processes and education

Ensure all compliance requirements are met

Quality reviews of refund activity

Required Qualifications

Bachelor's degree or equivalent experience

4 - 5 years or more of technical experience (Executive Level Summary, Relational Databases)

Strong background in Claims (Operational claims knowledge including facility reimbursement methodology), SIU, Audits and Financial Recovery

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Experience with Analysis and Executive Level Summaries

Experience with Financial Recovery Processes

Capability to compile and analyze information from various data streams

Background working with Audits and the approval of production processes

Process implementation to enhance efficiencies and improve outcomes

Experience meeting Compliance Requirements and Quality Reviews of refund activity

Exception verbal and written Communication skills; background working Stakeholders and Internal / External groups

Work shift will be in Eastern Time Zone

Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) is required.

A dedicated home office space, with a locked door, lacking ongoing interruptions to protect member PHI / HIPAA information

Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test

Additional Information

The following policy applies ONLY to associates working in the state of Arizona :

Humana is committed to providing a safe and healthy work environment and to promoting the health and well-being of its associates. Effective July 1, 2011, Humana has adopted a tobacco-free hiring policy that will promote a healthier workplace and will not hire users of tobacco and nicotine products. If you have any questions, please consult with your recruiter.

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com