Senior Claims Compliance Professional

Humana

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

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

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in auditing claims for compliance with regulatory standards and Humana policies, utilizing data analysis tools to drive process improvements and maintain accurate documentation. Strong communication skills are essential for presenting findings and collaborating with internal and external partners.

Highest-signal resume keywords

Claims Audit ExperienceRegulatory Compliance KnowledgeData Analysis ProficiencyStrong Communication SkillsAttention to Detail

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ProcessingAudit MethodologyICD CodingCPT CodingHCPCS CodingProcess ImprovementReport DevelopmentRoot Cause AnalysisSampling TechniquesDelegation Laws Knowledge

Soft Skills

Strong Written CommunicationStrong Verbal CommunicationAbility to Manage Multiple PrioritiesInfluencing SkillsProfessional Representation

Tools & Technologies

MS WordMS ExcelMS PowerPointAudit SoftwareData Analysis Tools

Certifications & Qualifications

CHCCCEPCPCCIACFE

Industry Keywords

State RegulationsFederal RegulationsAccreditation StandardsCMSNCQAPHIHIPAA

About the role

Key responsibilities & impact

Perform oversight audits of claims delegates for compliance with state and federal regulations and Humana standards
Serve as primary point of contact for assigned claims delegates
Audit medical, mental health and vision claims
Drive corrective actions through resolution and monitor implementation
Develop and maintain relationships with internal and external business partners and delegates
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
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
Report to a Compliance Lead
Travel to site delegations and occasionally Humana offices for training or meetings

Requirements

What you’ll need

2+ years of claims and/or audit experience
Knowledge/understanding of claims
Demonstrated proficiency in MS Word, Excel and PowerPoint
Knowledge/understanding of regulatory and legislative requirements including state and federal regulations and accreditation standards
Ability to travel up to 20% to site delegations
Process improvement knowledge
Strong written and verbal communication skills
Strong attention to detail
Ability to manage multiple or competing priorities and meet deadlines
Ability to perform work assignments without direction and exercise considerable latitude in determining objectives and approaches
Ability to present audit findings and influence delegates to resolve deficiencies
Ability to represent Humana professionally when working with external delegates
Preferred: Bachelor’s degree
Preferred experience with delegation laws, regulations and accreditation requirements, such as CMS, NCQA and applicable state requirements
Preferred claims and auditing experience, including medical, mental health or vision claims
Preferred working knowledge of ICD, CPT and HCPCS coding standards
Preferred experience with audit methodology, including sampling, root cause analysis and scorecards or dashboards
Preferred experience using data analysis or audit tools
Preferred project coordination or management experience
Preferred metrics and report development experience
Preferred vendor management experience
Preferred certifications such as CHC, CCEP, CPC, CIA or CFE
Must work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information
Home internet must provide at least 25 Mbps download and 10 Mbps upload speeds

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
Dedicated workspace and internet requirements for home/hybrid work
Occasional travel to Humana offices for training or meetings