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Senior Compliance Professional

2 months ago

Augusta, United States Humana Full time

Humana Senior Compliance Professional - Augusta, Maine

Become a part of our caring community and help us put health first. The Senior Compliance Professional ensures compliance with governmental requirements. The Senior Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. The Senior Compliance Professional's primary focus will be to develop and implement a plan to monitor and audit business processes to prevent, detect, and resolve compliance issues to help ensure an effective compliance program for Claims, COB (Coordination of Benefits), Subrogation, and Provider Payment Integrity for the Medicare line of business. The Senior Compliance Professional develops and implements compliance policies and procedures. Researches compliance issues and recommends changes that assure compliance with contract obligations. Maintains relationships with government agencies. Begins to influence department's strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments. Key responsibilities may include: Research, understand and apply laws, regulations, and regulatory guidance for Claims, COB (Coordination of Benefits), Subrogation, Provider Payment. Serve as the subject matter expert on Claims, COB (Coordination of Benefits), Subrogation, Provider Payment Integrity. Develop audit methodology and perform auditing and monitoring activity to prevent and detect issues of noncompliance and provide guidance on remedial actions to strengthen compliance controls and ensure compliance with state and federal laws and regulations. Analyze business requirements and complex issues, conduct research, and provide regulatory guidance to business partners, Law, and Enterprise Compliance associates and leaders with regard to Claims, COB (Coordination of Benefits), Subrogation, Provider Payment Integrity. Develop and track compliance metrics to help monitor and detect potential compliance issues. Partner with Enterprise Compliance team members on regulatory outreach. Serve as the Regulatory Compliance subject matter expert during CMS program audits. Lead onsite program audit preparation and activity and perform oversight of business audit preparation to ensure timely, accurate and complete submission of required data and documentation to regulators. Present findings of monitoring and auditing efforts to business partners and Enterprise Compliance leaders and track issue to ensure appropriate and timely remediation. Lead and participate on committees, providing compliance guidance and direction. Provide back-up and support to other Enterprise Compliance team members and perform other duties, as needed. Use your skills to make an impact. Required Qualifications: 5 or more years of technical experience Knowledge/understanding of laws and regulations governed by the Department of Insurance and CMS Preferred Qualifications: Graduate or advanced degree Audit or consulting experience Experience with metrics and reporting

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