Sr. Claims Compliance Professional

Humana • Louisville, KY

23h • $86,300 - $118,700 • Remote

About The Position

Humana is seeking a Senior Compliance Professional to oversee claims delegates and help ensure compliance with current state and federal regulations, accreditation standards, contractual requirements, and Humana standards. The role audits medical, mental health, and vision claims and supports corrective action through resolution, helping Humana and its delegates remain audit ready.

The position serves as the primary point of contact for assigned claims delegates and develops relationships with internal and external business partners. It reviews delegate policies, procedures, and claims files for accuracy, completeness, and compliance, including validating coding, billing practices, and documentation. The professional tracks and reports audit information, prepares detailed audit reports, presents findings, and maintains documentation of oversight activities and compliance status.

The role monitors corrective action plans and their implementation, uses data analysis tools and audit software to identify trends and support quality assurance, and collaborates with claims processors and compliance teams to resolve issues and improve processes. It also assists with special projects, develops and updates oversight policies, procedures, and training materials, and supports readiness for regulatory audits and accreditation surveys.

This is a remote U.S. position, with a hybrid workstyle for employees located in Louisville, Kentucky. Occasional travel to Humana offices for training or meetings may be required. The position is scheduled for 40 hours per week. Home or hybrid employees must have internet service with at least 25 Mbps download and 10 Mbps upload speeds and work from a dedicated space that protects member PHI/HIPAA information.

Requirements

• At least 2 years of claims and/or audit experience.
• Knowledge or understanding of claims.
• Ability to represent Humana professionally when working with external delegates.
• Proficiency with Microsoft Word, Excel, and PowerPoint.
• Knowledge or understanding of regulatory and legislative requirements, including state and federal regulations and accreditation standards.
• Excellent oral and written communication skills, including the ability to present audit findings and influence delegates to resolve deficiencies.
• Ability to travel 20%.

Nice To Haves

• Bachelor’s degree.
• Experience with delegation laws, regulations, and accreditation requirements, such as CMS, NCQA, and applicable state requirements.
• Claims auditing experience involving medical, mental health, or vision claims.
• Working knowledge of ICD, CPT, and HCPCS coding standards and ability to validate coding, billing, and documentation against regulatory requirements.
• Experience with audit methodologies such as sampling, root cause analysis, and scorecards or dashboards.
• Experience using data analysis or audit tools to monitor trends and support quality assurance.
• Project coordination or management experience.
• Metrics and report development experience.
• Vendor management experience.
• Certifications such as CHC, CCEP, CPC, CIA, or CFE.

Responsibilities

• Perform oversight audits of assigned claims delegates to assess compliance with state and federal regulations, accreditation standards, contractual requirements, and Humana standards.
• Review delegate policies and procedures and medical, mental health, and vision claims files for accuracy, completeness, and compliance.
• Validate coding, billing practices, and documentation against regulatory and legislative requirements.
• Track, report, and communicate audit information to delegates and required internal departments.
• Prepare detailed audit reports and present findings to management and relevant stakeholders.
• Issue corrective action plans when applicable, monitor implementation, and follow up with delegates until issues are resolved and compliance is sustained.
• Serve as the primary point of contact for assigned claims delegates.
• Develop and maintain relationships with delegates and internal and external business partners.
• Maintain detailed documentation of oversight activities, audit results, and compliance status.
• 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.
• Help develop and update delegated oversight policies, procedures, and training materials.
• Support readiness for regulatory audits and accreditation surveys.
• Assist with special projects that promote department efficiency.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, company holidays, and personal holidays.
• Paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.
• Bonus incentive plan based on company and/or individual performance.
• Other opportunities supporting personal wellness and smart healthcare decisions.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: No Education Listed