Senior Process Improvement Professional

Become a part of our caring community and help us put health first
 

Join MRT as a Senior Process Improvement Professional — Drive Impact and Innovation in Healthcare!

Are you ready to elevate your career in a role that blends strategy, analysis, and real-world impact? As a Senior Process Improvement Professional on the Medicare Medicaid Resource Team, you’ll be at the heart of our rapidly evolving Medicaid and Medicare operations, driving meaningful change in a fast-paced, collaborative environment.

In this position, you’ll have the unique opportunity to engage with senior executives and cross-functional teams, guiding critical improvements that directly affect the lives of our members. Your expertise will inform best-in-class processes and policies, ensuring Humana remains at the forefront of healthcare innovation. Come thrive in a collaborative environment where teammates support one another, celebrate successes together, and bring positivity and even laughter to their work, demonstrating that teamwork and a sense of camaraderie are key to getting the job done.

Key Responsibilities:

Natural Disaster and Cyber Event Claims Processing

• This role manages all initial claims processing impacts resulting from Natural Disaster Declarations and Cyber Events, including authorization and referral bypasses, as well as timely filing guideline adjustments.

Code Mapping for Accurate Authorization Matching

• The position is responsible for mapping all CPT, HCPCS, and Revenue codes to the correct service category in CAS. This mapping drives critical referral and HMO outpatient authorization matching logic.

Feasibility Assessments for New Benefits

• The role conducts feasibility assessments for proposed new benefits, with 64 feasibility notifications processed in 2024.

Medicaid State Claims Processing Support

• Provides specialized claims processing support for South Carolina, Oklahoma, Michigan, and for the upcoming Georgia Medicaid programs.
• Responsible for reviewing and responding to LRR/Impact Analysis Questionnaires from state agencies and implementing process updates to comply with new regulations under accelerated timelines.
• Conduct in-depth research on claims, compliance, and legislative requirements to inform process updates and claims payment recommendations.

Use your skills to make an impact
 

Required Qualifications

• Minimum 2 years of claims processing experience utilizing CAS
• Minimum 2 years of experience following claims processing and/or edit documents in Mentor
• Experience taking a processed claim and determining what edits/processes the claim hit as well as following the processing guidelines to determine if the claim processed appropriately and if it paid the correct benefits per the members plan and providers contract
• Experience utilizing CRM
• Proficiency with Microsoft Office Word and Excel including the ability to create pivot tables
• Demonstrated experience in root cause analysis and investigation
• Strong research skills, with a proven ability to learn quickly and identify improvement opportunities
• Comfortable making independent decisions in a dynamic environment
• Exceptional attention to detail and accuracy in your work
• Ability to switch tasks and adapt priorities as needed
• Experience collaborating and communicating effectively with a wide range of stakeholders

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

• Experience with Medicare/Medicaid state regulations and guidelines
• Experience creating claims process, claims adjudication, or compliance policy in relation to various projects
• Experience utilizing SQL to use and manipulate various forms of data
• CIS/CIS Pro experience
• Ability to navigate through the CMS database
• Understanding of how to locate and interpret member benefits
• Understanding of Plan Load
• Understanding of coding

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 HireVue. HireVue 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 if you will be moving forward to next round of interviews.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

 

$78,400 - $107,800 per year

 

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

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.

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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 protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with 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.