Payment Integrity Professoinal 2

Humana Inc. Green Bay , WI 54302

Posted 6 months ago


The Payment Integrity Professional 2 uses technology and data mining, detects anomalies in data to identify and collect overpayment of claims. Contributes to the investigations of fraud waste and our financial recovery. The Payment Integrity Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.


The Payment Integrity Professional 2 contributes to overall cost reduction, by increasing the accuracy of provider contract payments in our payer systems, and by ensuring correct claims payment in a Prepayment Auditing environment. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Primary Responsibilities

  • Collaborate with Audit associates, leaders and managers as well as internal Humana partners

  • Proactively research and determine root cause analysis and make recommendations

  • Facilitates discovery of new opportunities for program growth and support ongoing program performance

  • Coordinates and conducts thorough research of clinical and SIU data validation within THOR system compared to Legacy

  • Support data interpretation for process enhancements, performance, efficiency and determining process gaps

Required Qualifications

  • 1-5 years' work experience processing, reading and interpreting claims on CAS and/or MTV

  • Proficient in Microsoft Office Programs Word, PowerPoint, and Excel

  • Strong attention to detail

  • Ability to work independently and determine appropriate courses of action

  • Ability to handle multiple priorities

  • Capacity to maintain confidentiality

  • Excellent written and verbal communication skills

  • Experience in a fast paced, metric driven, operational setting

Preferred Qualifications

  • Bachelor's Degree or higher

  • Experience leading people, projects, and/or processes

  • Experience in CCM

  • Experience with data reviews, making determinations and presenting results/solutions

  • Experience using the following systems: CISpro and CIS

  • Knowledge of Microsoft Programs: EDW, QL, Access and Project

Scheduled Weekly Hours

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Payment Integrity Professoinal 2

Humana Inc.