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The organization in which the VP will be working is responsible for: proactively monitoring claim payments to limit Humana's exposure to fraudulent, abusive, and wasteful provider billing practices.
The VP Claims Payment Integrity Operationswill provide strategic leadership and operational support related to key functions that monitors the accuracy of claim payments to limit Humana's exposure to fraudulent, wasteful, and abusive healthcare billing practices.
The leader will need in-depth knowledge and expertise in working in large, complex operational organizations. Scope of the role will include knowing and understanding our different lines of business: Medicare, Medicaid and Specialty.
Scope also includes operational support with vendor partnerships, contract reviews, sourcing new capabilities, creating efficiencies, and influencing change across the enterprise that enhances the consumer experience and ensure we are appropriately paying claims to our providers.
The VP must be an experienced leader with a demonstrated record of driving significant results across large and complex organizations in a collaborative and engaging manner. This leader will guide the operational team to identify improvement opportunities, including cross-training initiatives and cost transformation. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes. The operational team is responsible for day-to-day run the business which includes resolving inquiries, meeting compliance expectations, managing vendor partners, and focusing on claim payment trends and identifying way to mitigate utilization trends.
Core responsibilities include:
This leader will oversee 900+ Humana associates and a 2500+ contingent worker footprint. The leader will have 5 direct reports and will be responsible for managing the budget for all the operational areas mentioned above.
Use your skills to make an impact
Required Qualifications
Preferred Qualifications
Scheduled Weekly Hours
40
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.
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 because he or she is a protected veteran. It is also the policy of Humanato take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
The organization in which the VP will be working is responsible for: proactively monitoring claim payments to limit Humana's exposure to fraudulent, abusive, and wasteful provider billing practices.
The VP Claims Payment Integrity Operationswill provide strategic leadership and operational support related to key functions that monitors the accuracy of claim payments to limit Humana's exposure to fraudulent, wasteful, and abusive healthcare billing practices.
The leader will need in-depth knowledge and expertise in working in large, complex operational organizations. Scope of the role will include knowing and understanding our different lines of business: Medicare, Medicaid and Specialty.
Scope also includes operational support with vendor partnerships, contract reviews, sourcing new capabilities, creating efficiencies, and influencing change across the enterprise that enhances the consumer experience and ensure we are appropriately paying claims to our providers.
The VP must be an experienced leader with a demonstrated record of driving significant results across large and complex organizations in a collaborative and engaging manner. This leader will guide the operational team to identify improvement opportunities, including cross-training initiatives and cost transformation. Decisions are typically related to the implementation of new/updated programs or large-scale projects for the function and supporting technical/operational procedures and processes. The operational team is responsible for day-to-day run the business which includes resolving inquiries, meeting compliance expectations, managing vendor partners, and focusing on claim payment trends and identifying way to mitigate utilization trends.
Core responsibilities include:
- Code edit
- Medical Record review
- Fraud, Waste, investigations: provider, member, agent - all lines of business
- Subrogation
- Compliance, and education
- Vendor invoicing
- Medicaid strategy
- Building strong partnerships with key stakeholders across the enterprise
- Creating a culture that maximizes associate engagement, wellbeing, inclusion, and diversity.
- Ability to manage multiple tasks, priorities, and deadlines with diligence
- Ability to understand and manage through state and regulatory compliance
- Experience evaluating and negotiating vendor solutions
This leader will oversee 900+ Humana associates and a 2500+ contingent worker footprint. The leader will have 5 direct reports and will be responsible for managing the budget for all the operational areas mentioned above.
Use your skills to make an impact
Required Qualifications
- Bachelor's degree, preferably in a business-related field
- 8+ or more years of management experience (leading a large team within Operations environment at a large corporation)
- 5 or more years of healthcare/managed care industry experience
- Proven ability to excel in a dynamic, changing, and fast-paced environment
- Prior leadership experience driving process improvement, leveraging data and analytics, and ensuring regulatory compliance
- A strong commitment to team and professional development, with demonstrated ability to hire, mentor, and develop future leadership talent
- Strong computer skills (e.g. Excel, Word, PowerPoint and other programs required for assimilating and presenting reports)
- Excellent communication and presentation skills to include the ability to communicate and present technical details to other VP and Senior VP leadership.
- Sound business and financial acumen with ability to apply knowledge to business challenges
Preferred Qualifications
- Advanced degree
- Experience with Provider
- Strong digital and technical acumen with implementation or significant change experience
- Exceptional Operational experience ideally working within a large matrixed organization.
Scheduled Weekly Hours
40
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.
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 because he or she is a protected veteran. It is also the policy of Humanato take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.
