Medicaid Reconciliation Professional II

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

The Medicaid Process Improvement Professional 2 is responsible for analyzing and evaluating the effectiveness of existing Medicaid business processes, with a focus on eligibility, enrollment, claims, and compliance workflows. This role develops sustainable, repeatable, and measurable improvements that align with Medicaid program requirements and regulatory standards.

Assignments are varied and often require interpretation of Medicaid-specific policies and data. The role demands independent judgment to determine the most appropriate course of action, particularly when addressing operational inefficiencies, system discrepancies, or member-level variances. The professional collaborates closely with cross-functional teams, including state agencies, managed care organizations, and internal stakeholders, to drive process enhancements that improve member outcomes and operational accuracy.

The Medicaid Reconciliation Professional II supports process improvement initiatives by analyzing and enhancing Medicaid-related financial and operational workflows. This role involves researching best practices within and outside the organization to establish benchmarks and improve reconciliation accuracy, timeliness, and compliance. The ideal candidate should possess strong attention to detail with the ability to identify and resolve discrepancies and the ability to interpret and apply Medicaid policies and procedures.

Key responsibilities include:

• Data Collection & Analysis:
  Gather and evaluate Medicaid eligibility data to identify discrepancies and opportunities for process optimization and state submissions

• Process Enhancement:
  Collaborate with the Senior Professional and Leads and recommend and implement business practices that improve reconciliation efficiency, reduce errors, and support regulatory compliance

• Technology Integration:
  Assess how new systems and tools can streamline Medicaid reconciliation processes and support automation efforts

• Share feedback with the Senior Business Systems analysis associate for appropriate fix implementation

• Strategic Alignment:
  Understand departmental and organizational goals, ensuring reconciliation processes align with broader Medicaid and healthcare compliance strategies

• Decision-Making:
  Exercise independent judgment in routine tasks and contribute to problem-solving in ambiguous situations with minimal supervision

• Guideline Adherence:
  Follow established procedures while identifying areas for improvement and innovation

Key Performance Indicators (KPIs)

• Reconciliation Accuracy Rate:
  Percentage of Medicaid claims and payments accurately reconciled without discrepancies

• Timeliness of Reconciliation:
  Average time taken to complete reconciliation cycles within reporting deadlines.

• Comply with established due dates

• Error Reduction Rate:
  Year-over-year decrease in reconciliation errors or mismatches

• Process Improvement Implementation:
  Number of process improvement initiatives successfully implemented and sustained

• Compliance Rate:
  Adherence to Medicaid regulations and audit requirements

Use your skills to make an impact

Required Qualifications

• Undergraduate degree

• Minimum 3 years of experience in Medicaid reconciliation enrollment

• Minimum 3 years of experience with process improvement initiatives

• Demonstrated experience with data analysis and reporting tools (e.g., Excel, Access, or similar)

• Proficiency in Microsoft Office Suite, especially Excel (pivot tables, VLOOKUP, formulas)

• Familiarity with Medicaid systems, claims platforms, and reconciliation tools

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 data visualization tools (e.g., Power BI, Tableau)

• Familiarity with SQL or other data querying languages

• Experience working in cross-functional teams to drive operational efficiency

• Proven track record of identifying and implementing process enhancements

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 Hire Vue. Hire Vue 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…