Associate Director, Prepay Payment Integrity

Become a part of our caring community and help us put health first
 The Associate Director, Prepay Payment Integrity 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 Associate Director, Prepay Payment Integrity requires a solid understanding of how organization capabilities interrelate across department(s).

This role has ownership for Prepay Audit Operations performance with oversight to inventory, improving accuracy of claim payments and contributing to overall cost efficiency.   You will work cross functionally with Clinical, SIU, Claims Process Organization, Markets and Provider Contracting on best and seamless claim practices as well as develop and lead presentations to senior leaders in those areas. This entails:

• Has 5-7 direct reports, 90 indirect Humana associates and 500 BPO (outsourced) associates
• Partners with finance on staffing model, medical cost savings forecasting and budget
• Ensures contractual adherence of BPO partner performance and invoice reconciliation
• Assures that claim compliance across the organization for Medicare and Medicaid is achieved
• Creates and supports a Health First work environment and a culture of caring, curious and committed associates

In addition to being a great place to work, Humana also offers industry leading benefits for all employees, starting your FIRST day of employment. Benefits include:

• Medical Benefits
• Dental Benefits
• Vision Benefits
• Health Savings Accounts
• Flex Spending Accounts
• Life Insurance
• 401(k)
• PTO including 9 paid holidays, one personal holiday, one day of volunteer time off, 23 days of annual PTO, parental leave, caregiving leave, and weekly well-being time
• And more

Use your skills to make an impact
 

Required Qualifications

• 4+ years of work experience related to medical claims
• 3+ years' people management experience
• 3+ years' of inventory management experience
• Comprehensive knowledge of Microsoft Office Programs Word, PowerPoint, and Excel
• Experience facilitating, consulting, and delivering complex concepts or projects
• Able to determine the needed approach, resources, and goals to meet business objectives
• Demonstrated experience with cross departmental collaboration
• Ability to handle multiple priorities
• Capacity to maintain confidentiality
• Excellent communication skills both written and verbal

Preferred Qualifications

• Experience with Claims Processing within CAS and/or MTV systems
• Bachelor's Degree
• Experience in Payment Integrity
• Bilingual (English/Spanish) with the ability to read, write, and speak English and Spanish

Additional Information

Work at Home/Remote Requirements

Work-At-Home Requirements

• To ensure Home or Hybrid Home/Office associates’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office associates must meet the following criteria:
  • At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended to support Humana applications, per associate.
  • Wireless, Wired Cable or DSL connection is suggested.
  • Satellite, cellular and microwave connection can be used only if they provide an optimal connection for associates. The use of these methods must be approved by leadership.  (See Wireless, Wired Cable or DSL Connection in Exceptions, Section 7.0 in this policy.)
  • Humana will not pay for or reimburse Home or Hybrid Home/Office associates for any portion of the cost of their self-provided internet service, with the exception of associates who live or work from Home in the state of California, Illinois, Montana, or South Dakota.  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

Our Hiring Process

As part of our hiring process, we will be using an exciting interviewing technology provided by HireVue, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging, and/or Video Interview.  If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone or computer. You should anticipate this interview to take approximately 10-15 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

If you have additional questions regarding this role posting and are an Internal Candidate, please send them to the Ask A Recruiter persona by visiting go/Buzz and searching Ask A Recruiter! Please be sure to provide the requisition number so we may be able to research your request quicker.

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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.

$104,000 - $143,000 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.Application Deadline: 03-11-2025
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.

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 veteran status. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.