Unknown Company is hiring a Risk Management Professional

Humana is hiring a Risk Management Professional to safeguard the payment quality of TRICARE claims. This critical role involves reviewing pre-payment, high-dollar claims to assess accuracy, identify risks, and provide actionable feedback to mitigate organizational risk and support quality goals.

What You'll Do

• Conduct daily high dollar claim quality audit reviews using strong analytical, technical, and communication skills and a comprehensive understanding of TRICARE policies.
• Make approval and processing determinations for payment release.
• Conduct focused claim studies and perform duplicate claim detection through the DHA Duplicate Claims System (DCS).
• Research and review claims for internal focus audits to identify potential payment error risks, areas for improvement, and possible system issues.
• Develop and recommend controls and cost-effective approaches to minimize claims processing risks.
• Perform advanced administrative, operational, and customer support duties that require independent initiative and judgment.
• Assist in special projects as directed by Department Management.

What We're Looking For

• U.S. Citizenship (Department of Defense contract requirement).
• Successfully receive interim approval for government security clearance (NBIS - National Background Investigation Services).
• Cannot be currently living in Puerto Rico (HGB not authorized to do work in Puerto Rico per government contract).
• 2 years TRICARE claims experience to include professional and institutional claims reimbursement.
• Strong knowledge of TRICARE policy and claims processing.

Nice to Have

• Bachelor’s degree.

Technical Stack

• DHA Duplicate Claims System (DCS)

Benefits & Compensation

• Compensation: $65,000 - $88,600 per year
• 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.

Work Mode

This is a hybrid role with remote locations.

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.