Role Description Become a part of our caring community. Internal Audit drives the achievement of Humana's strategic and financial objectives. The Senior Internal Auditor provides value-added service by evaluating the efficiency and effectiveness of Humana's operational processes. The Senior Internal Auditor owns audit engagements by leading walkthrough discussions, performing detail reviews, and identifying process gaps within business processes. The Senior Internal Auditor makes decisions on moderately complex to complex issues and performs work with limited guidance. - Lead engagements while establishing own work priorities and timelines - Conduct process walkthroughs with business owners to assess the design of internal controls - Review testing of key controls to ensure internal controls and processes are designed and operating effectively - Identify audit issues and root causes, recommend improvements, and effectively work with business partners to remediate outstanding issues - Provide constructive on-the-job feedback and mentoring throughout projects to staff and interns - Conduct operational, compliance, financial and investigative audits that may require in-depth evaluation and judgment - Determine the scope of audits to best evaluate the adequacy and effectiveness of the systems and controls under audit - Help develop the risk-based audit plan, including risk identification - Provide leadership to departmental committees and initiatives Qualifications - Bachelor's degree in Accounting or related field - 3 or more years of audit or consulting experience - Experience facilitating and consulting across teams and managing projects - Ability to prioritize tasks and projects, while focusing on the "big picture" - Aptitude for establishing working relationships with associates within the department and the business Requirements - Certifications such as CPA, CIA, CISA, CISSP, PMP, CFE - Advanced degree preferred - Data Analytics / Business Intelligence experience a plus. Prior experience with data analytics tools, including but not limited to, PowerBI, Alteryx, Tableau, SQL, R & Python - Six Sigma Black Belt, Process Improvement and/or Quality Control expertise - Prior healthcare experience with processes, audit practices, and project management principles Benefits - Competitive benefits that support whole-person well-being - Medical, dental and vision benefits - 401(k) retirement savings plan - Time off (including paid time off, company and personal holidays, paid parental and caregiver leave) - Short-term and long-term disability - Life insurance and many other opportunities Additional Information - Humana's Louisville headquarters is the preferred location; qualified remote candidates located outside of Louisville, KY, will also be considered - You must be willing to work standard daytime hours in either the Eastern or Central time zone - Work at Home Requirements: Minimum download speed of 25 Mbps and upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested - 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 based upon company and/or individual performance

Role Description Imagine360 is seeking a Stop Loss Claims Auditor to join the team! This position is part of the Stop Loss Department and supports multiple functions within the department including, but not limited to, claims examination, auditing, reviewing, and processing. The person in this position must demonstrate a proficient knowledge of all Stop Loss processes and procedures. Position Location: 100% remote Responsibilities include but are not limited to: - Demonstrate above average technical knowledge of all aspects of the stop loss process, specifically the claims review process. - Monitor claims inbox and respond, in a timely fashion, to all incoming claims. - Compile and review all claims information including employer health plans, stop loss insurance contracts, provider documentation, and all other claim evidence. - Audit submitted claims for sufficient data, verifying that benefits are paid correctly and in accordance with appropriate plans and policies. - Prepare written rationale of claim decisions based on review of appropriate evidence, contracts, etc. - Set claim reserves and adjust as needed. - Enter appropriate stop loss claims and violations into designated database. - Identify, research, and resolve stop loss carrier questions or issues. - Facilitate advance funding with Finance Department. - Comply with reporting and documentation requirements. - Coordinate tracking and reporting of stop loss violation. - Manage large case notification process. - Manage various reporting requirements. - Notify claims team and/or underwriting staff of newly disclosed claimants or extremely high-risk claimants after review of incoming precertifications and reports. Customer Service - Receive and respond in a timely and accurate manner, both orally and in writing, to customer inquiries regarding claims and plan documents. - Act supportively and empathetically to internal and external customers. - Appropriately escalate difficult issues up the chain of command. - Model and provide an environment that supports Imagine360 core values to encourage continuous learning, personal development, and accountability. - Actively support company and department initiatives, supervisors, and other team members. Quality Assurance - Actively participate in team/department meetings and training initiatives. - Perform self-quality monitoring in order to develop and execute plans to meet established goals. - Provide ongoing feedback to help optimize quality performance. - Collaborate with staff and cross-departmentally to improve or streamline procedures. Qualifications - Associate or Bachelor's Degree or combination of experience and education. - 3-5 years of processing first dollar medical claims. - Processing Stop Loss Claims experience. - Prior experience in self-insured plan management. - Prior experience in Stop Loss Claims and Stop Loss industry. Requirements - Strong communication (telephonic, oral, and written), interpersonal relationship, analytical and problem-solving skills as well as detail oriented. - Working knowledge of computers and software including but not limited to Microsoft Office products. - Demonstrated ability to work independently, prioritize workloads, multi-task and manage priorities in order to meet deadlines. - Knowledge of legal risks and regulatory/statutory guidelines of HIPAA, privacy, Patient Protection and Affordable Care Act, etc. - Knowledge of Medical Terminology, CPT (Current Procedural Terminology), and International Classifications of Diseases (ICD-10). Benefits - Multiple Health plan options. - Company paid employee premiums for disability and life insurance. - Parental Leave Policy. - 20 days PTO to start / 10 Paid Holidays. - Tuition reimbursement. - 401k Company contribution. - Company paid Short & Long term Disability plus Life Insurance. - Professional development initiatives / continuous learning opportunities. - Opportunities to participate in and support the company's diversity and inclusion initiatives.

• Responsible for the auditing of coders and/or "audit the auditors" to ensure coding accuracy of a minimum of 95% is met. • Perform quality checks/audits on visits coded as per client SOPs. • May assist in preparing audit reports, share direct feedback to coders and auditors. • Conduct analysis and present summary of findings to leadership in a clear, concise, convincing format. • Maintain a high degree of professional and ethical standards.

Role Description Audit and authorize reimbursement of specific medical stop loss claims. Effectively mitigate client medical stop loss claims and provide excellent customer service. This position is full-time (40 hours/week) Monday-Friday from 8:00am-5:00pm EST and will be fully remote. What You’ll Do: - Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier. - Recognize cost mitigation opportunities. - Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits. - Initiate claims investigations and vendor referrals. - Interpret plan language, and identify experimental services and subrogation opportunities. - Identify need for follow-up on pended claims and resolution. - Communicate effectively with carriers, vendors, and management. - Provide full claims service to both phone and written inquiries. - Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history. - Develop new and review old stop loss claim forms. - Assist with internal auditing of claims auditors, and training of claims auditors. Qualifications - Required Education: Associate's Degree - Equivalency: 2 years of job-related work experience - Required Work Experience: 6 years of managed care or reinsurance claims experience. Requirements - Preferred Skills and Abilities: - Analyzes laws, regulations and contract language. - Evaluates issues and develops recommendations. - Handles confidential and sensitive information. - Investigates assigned claims. - Proposes claims adjustments and refunds. - Works claims caseloads. - Aggregate claims experience. Benefits - Subsidized health plans, dental and vision coverage - 401k retirement savings plan with company match - Life Insurance - Paid Time Off (PTO) - On-site cafeterias and fitness centers in major locations - Education Assistance - Service Recognition - National discounts to movies, theaters, zoos, theme parks and more