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The Senior Risk Management Professional identifies and analyzes potential sources of loss to minimize risk. The Senior Risk Management Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

The Senior Claims Risk Management Professional will ensure claims payment quality in relation to our TRICARE policy requirements. The Senior Claims Risk Management Professional will investigate claims to identify errors and potential claim payment risks. They are expected to provide accurate, actionable and thorough feedback by completing quality audit reviews on a daily basis. Quality audit results are provided to operational areas to mitigate risk to the organization and further support quality related goals. The Senior Claims Risk Management Professional will regularly exercise discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and are expected to work under limited guidance due to previous experience and depth of knowledge of administrative processes and organizational knowledge.

KEY ACCOUNTABILITIES

• 70% -- This individual utilizes strong analytics, technical, and communication skills as well as deep, broad understanding of TRICARE policies to complete high dollar claim quality audit reviews, which consist of approval and processing determinations for release of payment. This individual is responsible for conducting focus claim studies and duplicating claim detection through the DHA Duplicate Claims System (DCS). 
• 15% -- This individual researches alleged claim payment errors for quarterly and annual government audits. Where appropriate, this individual prepares written rebuttal responses to alleged payment errors using exhibits and TRICARE Policy references as support.
• 5% -- This individual develops and recommends controls and cost-effective approaches to minimize claims processing risks
• 5% -- This individual will perform advanced administrative/operational/customer support duties that require independent initiative and judgment
• 5% -- This individual assists 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 approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
• Minimum 2 years of experience in TRICARE claims experience to include professional and institutional claims reimbursement
• Self-starter and able to succeed with minimal supervision or direct managerial oversight
• Strong analytical and decision making skills
• Familiarity with mainframe and personal computer applications
• Ability to work within deadlines, demonstrate independence and be able to self-manage in a production environment
• Comprehensive knowledge of Microsoft Office Applications including Word, Excel, and Access
• Excellent verbal communication skills

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

Preferred Qualifications

• Bachelor’s degree in accounting, business, or information systems, with significant accounting concentration
• Experience with statistical analytic software packages such as SAS, Tableau and/or other data presentation and analytical tools

Additional Information

• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called Modern Hire. Modern Hire Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
• If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed and you will subsequently be informed