Become a part of our caring community and help us put health first
The Director, Process Improvement provides direction and management to the claims processing vendor for claims reimbursements and operational activities to provide superior service to internal and external customers in support of the VA Community Care Network. The Director, Process Improvement coordinates with the Director, VA CCN Claims Oversight for alignment of accurate claims processing. Ensures a high level of quality in all areas while meeting or exceeding performance goals.
This position is created specifically to assist with Humana's efforts to secure and, if awarded, transition into a new business opportunity. Please note that continued employment in this role is expressly contingent upon Humana's receipt of the business opportunity and a satisfactory transition into the work. In the event Humana does not pursue the opportunity or determines that a timely and satisfactory transition cannot be achieved, employment may be subject to termination.
The Director of Claims Oversight will lead a dedicated team responsible to establish and maintain comprehensive oversight of the VA CCN payment invoicing process with a focus on vendor management and payment integrity. This role ensures timely reconciliation of VA payments, effective management of accounts receivable and recoupments, administration and oversight of X12 processes and files as well as coordination of banking and reporting activities. The Director will serve as a key liaison between internal stakeholders and claims vendors to optimize operational efficiency and compliance with regulatory standards.
Key Responsibilities:
Oversee claims processing activities performed by external vendors, ensuring accuracy, timeliness, and compliance with contractual and regulatory requirements.
Monitor and review claims payment processes, identifying opportunities for process improvement and risk mitigation.
Direct the reconciliation of claims payments, maintaining detailed records and ensuring resolution of discrepancies.
Manage accounts receivable and recoupment processes, coordinating with finance and provider relations teams to ensure timely recovery and reporting.
Lead banking coordination and reporting activities, working closely with finance to maintain transparency and accuracy in financial transactions related to claims.
Use your skills to make an impact
Required Qualifications
Our Department of Defense contract requires U.S. Citizenship for this role
Must 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.
Bachelor's degree in Accounting, Finance, Business, Health Care Administration, Government Contract Management, or Operations Management or if non-degree, must have at least 5 years of experience with TRICARE and/or VA CCN in claims or financial transaction area.
5 years of experience in a managed care environment and financial transactions and claims area
Experience with VA, TRICARE contracts and/or the military health care delivery system, and/or Medicare reimbursement
Experience with data analysis and making decisions using data
Work at Home Requirements
To ensure Hybrid Office/Home associates' ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria:
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
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
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.
$150,000 - $206,300 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.
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.
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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.
Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
