Director of Claims Processing and Payment Integrity

About the role

The Director, Claims Processing and Payment Integrity oversees adjudication of claims and uses technology and data mining to audit claims for accuracy, detect anomalies in data, and identify over‑ and under‑payment of claims. The role contributes to the accurate and timely processing of claims and investigations of fraud, waste, and financial recovery. It requires an in‑depth understanding of TPA business, claims processing, and how organizational capabilities interrelate across functions. The director also contributes to overall provider satisfaction by paying claims accurately and timely, and drives cost reduction by increasing the accuracy of provider contract payments in payer systems. Decisions typically involve implementing new or updated programs, large‑scale projects, supporting technical/operational procedures, executing strategic plans, securing new business contracts, driving goals and objectives, improving performance, and providing input into functional strategy.

Responsibilities

• Oversee adjudication of claims
• Use technology and data mining to audit claims for accuracy
• Detect anomalies in claims data
• Identify over‑ and under‑payment of claims
• Contribute to accurate and timely claims processing
• Lead investigations of fraud, waste, and financial recovery
• Enhance provider satisfaction through accurate, timely claim payments
• Reduce costs by improving accuracy of provider contract payments
• Implement new/updated programs and large‑scale projects
• Execute strategic plans and secure new business contracts
• Drive goals, objectives, and performance improvements
• Provide input into functional strategy

Requirements

• Bachelor’s degree, or equivalent combination of education and experience
• 8 or more years of Medicare and/or Medicaid claims management experience

Qualifications

• Master’s degree
• Experience leading projects and processes
• Experience in financial recovery
• Experience with Plexis and Oracle systems
• Knowledge of LucidChart or Visio
• Project Management Professional (PMP) certification
• Bilingual in Spanish and English
• Progressive experience in contracting or claims area within a health solutions industry

Skills

• Ability to determine needed approach, resources, and goals to meet business objectives
• Demonstrated experience with cross‑departmental collaboration
• Experienced facilitating, consulting, and delivering complex concepts
• Comprehensive knowledge of Microsoft Office programs (Word, PowerPoint, Excel)
• Ability to handle multiple priorities
• Capacity to maintain confidentiality
• Excellent written and verbal communication skills
• Proficiency in analyzing and interpreting financial trends
• Strong collaboration skills
• Passion for contributing to an organization focused on continuously improving consumer experiences

Benefits

Humana offers competitive benefits that support whole‑person well‑being, including medical, dental, and vision benefits; a 401(k) retirement savings plan; time off (paid time off, company and personal holidays, paid parental and caregiver leave); short‑term and long‑term disability; life insurance; and many other opportunities.

Pay

The compensation range is $138,900 – $191,000 per year. This position is eligible for a bonus incentive plan based on company and/or individual performance.

Schedule

Scheduled weekly hours: 40. Remote work is considered, but preference is for onsite work in Miramar, FL.