Senior Clinical Medical​/Financial Risk Evaluation Professional

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

The Senior Clinical Medical/Financial Risk Evaluation Professional is responsible for supporting the development, implementation and monitoring of medical/financial risk and healthcare fraud. The Senior Clinical Medical/Financial Risk Evaluation Professional work assignments involve moderately complex to complex fraud issues where the analysis of situations or data requires an in-depth clinical evaluation of variable factors.

The Senior Clinical Medical/Financial Risk Evaluation Professional queries robust data pipelines, performs statistical analyses, and translates findings into clear reports and dashboards for internal partners and leadership. Furthermore, they analyze data through a clinical evidence-based lens to uncover insights and effectively communicate a meaningful narrative that supports informed decision-making.

They provide clinical advice and perspectives on outliers and fraud analysis to associates throughout the department. Additionally, the Senior Clinical Medical/Financial Risk Evaluation Professional recommends plans for departmental efficiencies, initiates and coordinates cross-departmental collaborations, and conducts clinical training sessions across teams.

• Bachelor's degree
• Licensed Practical Nurse (LPN) or Licensed Registered Nurse (RN) without restriction in applicable state
• Minimum 5 years of experience with Humana or other healthcare claims systems
• Ability to do extensive research on a given topic
• Microsoft Excel skills (including sorting/filtering data and utilizing pivot tables)
• Proven ability to pull and analyze large data sets and effectively communicate a meaningful narrative with those findings
• Proven ability to perform clinical reviews and review medical records
• Ability to collaborate and create connections with outside Clinical areas
• Excellent presentation and communication skills, both oral and written
• Strong relationship building skills
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences

• Power
  
  BI and/or PL-SQL Experience
• MRM (Medical Records Management) Experience
• Knowledge of Behavior Health and/or Inpatient Healthcare

As part of our hiring process for this opportunity, we will be using an interviewing technology called Hire Vue to enhance our hiring and decision-making ability. Hire Vue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership.

Employees 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 employees 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.

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

40

$86,300 - $118,700 per year

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,…