KEY ACCOUNTABILITIES
Utilize strong analytical, technical, and communication skills, as well as a comprehensive understanding of TRICARE policies, to conduct daily high dollar claim quality audit reviews. Responsibilities include making approval and processing determinations for payment release, conducting focused claim studies, and performing duplicate claim detection through the DHA Duplicate Claims System (DCS).
Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues. These activities support the mitigation of financial risk and help ensure quality standards are met for quarterly and annual government audits. This process is conducted in accordance with organizational procedures for claims risk management and supports compliance with TRICARE policy requirements.
Develop and recommend controls and cost-effective approaches to minimize claims processing risks.
Will perform advanced administrative/operational/customer support duties that require independent initiative and judgment.
Assist in special projects as directed by Department Management.
Required Qualifications
Our Department of Defense contract requires U.S. Citizenship
Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services)
HGB is not authorized to do work in Puerto Rico per our government contract. We are not able to hire candidates that are currently living in Puerto Rico.
2 years TRICARE claims experience to include professional and institutional claims reimbursement
Strong knowledge of TRICARE policy and claims processing
Able to work 8 hour shift between the hours of 7 a.m. - 6 p.m. E.T.
Preferred Qualifications
Bachelor’s degree
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
Scheduled Weekly Hours
40Pay 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.
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.
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.