Job Details

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CenterWell Senior Primary Care (PCO) is a growing provider organization that currently operates about 340+ senior focused primary care centers in 15 states. The Regulatory Compliance team that supports the PCO is responsible for assessing, investigating, auditing, and validating the mitigation of compliance risk across the organization. This team ensures that healthcare providers align their operational practices with legal requirements while fostering collaborative relationships with business partners to uphold ethical standards and mitigate risks. The Senior Clinical Compliance Professional will support the Director of Compliance, by ensuring compliance with governmental requirements for clinics across both federal and state requirements. The work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. As the Senior Clinical Compliance Professional, you will develop and/or evaluate compliance policies and procedures. Research compliance issues and recommend changes that assure compliance with federal and/or state requirements related to Provider Clinic operations, billing, investigations, and processes. Coordinate site visits for regulators, coordinate implementation and compliance with corrective action plans, as needed. You will participate in all phases of the audit process including evaluating control design and adequacy, testing to ensure adherence with established policies and internal controls, and communicating issues and recommendations to management. Coordinate implementation and compliance with corrective action plans. Understand department, segment, and organizational strategy and operating objectives, including their linkages to related areas. In this role, you will serve as a regulatory compliance subject matter expert with the 2nd line of defense compliance function. Research compliance related issues and communicate those requirements to high-level business leaders within the PCO.

Key Responsibilities:

• Assess the compliance risks to PCO and leverage the assessment to design the auditing and monitoring activities included in the workplan.
• Execute assigned portions of the PCO compliance workplan throughout the year.
• Regularly conduct compliance related audits to assess internal controls, examining healthcare records and processes, and analyzing and reporting risks.
• Influence department strategy by identifying and overseeing the development of continuous monitoring activities.
• Provide reporting on metrics and M&A activity related to revenue cycle management.

Use your skills to make an impact

Required Qualifications:

• Bachelors degree
• 3 or more years of healthcare experience in revenue cycle management (related to billing, coding, collections for Medicare and Medicaid claims)
• Experience with auditing and monitoring of healthcare records
• Must be able to work core business hours on EST time between (9am-5pm)
• Willingness to travel up to 10% to conduct audits at site locations
• Ability to manage multiple or competing priorities and meet deadlines
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Effective verbal and written communication skills
• Strong attention to detail
• Ability to articulate findings and impacts
• Knowledge/understanding of laws and regulations governed by the Department of Insurance and CMS

Preferred Qualifications:

• Compliance regulations knowledge and compliance auditing experience
• Ability to analyze large data sets
• Knowledge of healthcare compliance, mainly primary care and risk adjustment, pharmacy knowledge a plus
• Certified Coder (CPC, CRC, and/or CMC)
• Experience with metrics and reporting

Additional Information:

Work-At-Home Requirements:

• 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.

Interview Format:

As part of our hiring process for this opportunity, we will be using an exciting interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information for you pertaining to your relevant skills and experience at a time that is best for your schedule. If you are selected for a first-round interview, you will receive an email correspondence inviting you to participate in a HireVue interview. In this interview, you will receive a set of interview questions over your phone, and you will provide recorded or text message responses to each question. You should anticipate this interview to take about 15-20 minutes. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews. 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: $86,300 - $118,700 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.

Application Deadline: 08-07-2025

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.

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.