Senior Claims Compliance Professional

Humana

. Perform oversight audits of claims delegates for compliance with state and federal regulations and Humana standards .

Posted 11/9/2026full-timeRemote • United StatesSenior💰 $86,300 - $118,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in claims auditing and compliance oversight, with a strong understanding of regulatory requirements and the ability to effectively communicate findings and implement corrective actions. Proficient in data analysis and audit methodologies to enhance quality assurance and operational efficiency.

Highest-signal resume keywords

Claims Auditing ExperienceRegulatory Compliance KnowledgeData Analysis Tools ProficiencyExcellent Communication SkillsProject Coordination Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AuditingRegulatory Requirements KnowledgeCoding Standards (ICD, CPT, HCPCS)Audit MethodologyData AnalysisMetrics DevelopmentReport DevelopmentCorrective Action PlanningQuality AssuranceDelegation Laws Understanding

Soft Skills

ProfessionalismInfluencing SkillsCollaborationRelationship ManagementCommunication

Tools & Technologies

MS WordMS ExcelMS PowerPointAudit SoftwareData Analysis Tools

Certifications & Qualifications

CHCCCEPCPCCIACFE

Industry Keywords

Claims ProcessingAccreditation StandardsCMSNCQAState Regulations

About the role

Key responsibilities & impact

Perform oversight audits of claims delegates for compliance with state and federal regulations and Humana standards
Serve as the primary point of contact for assigned claims delegates
Audit medical, mental health and vision claims
Track, report and communicate audit information to delegates and internal departments
Prepare detailed audit reports and present findings to management and stakeholders
Review delegate policies, procedures and claims files for accuracy, completeness and compliance
Validate coding, billing practices and documentation against regulatory and legislative requirements
Issue corrective action plans and monitor implementation through resolution
Develop and maintain relationships with assigned delegates
Maintain documentation of oversight activities, audit results and compliance status
Use data analysis tools and audit software to monitor trends and support quality assurance
Collaborate with claims processors and compliance teams to resolve issues and improve processes
Develop and update delegated oversight policies, procedures and training materials
Support readiness for regulatory audits and accreditation surveys
Assist with special projects that promote department efficiency

Requirements

What you’ll need

2+ years of claims and/or audit experience
Knowledge/understanding of claims
Ability to effectively represent Humana with a high level of professionalism when working with external delegates
Proficient knowledge of MS Word, Excel and PowerPoint
Knowledge/understanding of regulatory and legislative requirements, including state and federal regulations and accreditation standards
Excellent oral and written communication skills, including the ability to present audit findings and influence delegates to resolve deficiencies
Ability to travel 20%
Preferred: Bachelor’s degree
Experience with delegation laws, regulations and accreditation requirements, such as CMS, NCQA and applicable state requirements
Claims auditing experience, including medical, mental health or vision claims
Working knowledge of coding standards (ICD, CPT and HCPCS)
Experience with audit methodology, including sampling, root cause analysis and scorecards or dashboards
Experience using data analysis or audit tools to monitor trends and support quality assurance
Project coordination or management experience
Metrics and report development experience
Vendor management experience
Certifications such as CHC, CCEP, CPC, CIA or CFE

Benefits

Comp & perks

Bonus incentive plan based on company and/or individual performance
Medical, dental and vision benefits
401(k) retirement savings plan
Paid time off
Company and personal holidays
Paid parental and caregiver leave
Short-term and long-term disability
Life insurance
Work-from-home or hybrid work arrangement
Occasional travel to Humana offices for training or meetings
Internet service requirements/support for home or hybrid employees