Senior Clinical Medical / Financial Risk Evaluation Professional

Become a part of our caring community and help us put health first

The Senior Clinical Medical / Financial Risk Evaluation Professional is responsible for supporting the development, implementation and monitoring of medical / financial risk and healthcare fraud. The Senior Clinical Medical / Financial Risk Evaluation Professional work assignments involve moderately complex to complex fraud issues where the analysis of situations or data requires an in-depth clinical evaluation of variable factors.

The Senior Clinical Medical / Financial Risk Evaluation Professional queries robust data pipelines, performs statistical analyses, and translates findings into clear reports and dashboards for internal partners and leadership. Furthermore, they analyze data through a clinical evidence-based lens to uncover insights and effectively communicate a meaningful narrative that supports informed decision-making.

They provide clinical advice and perspectives on outliers and fraud analysis to associates throughout the department. Additionally, the Senior Clinical Medical / Financial Risk Evaluation Professional recommends plans for departmental efficiencies, initiates and coordinates cross-departmental collaborations, and conducts clinical training sessions across teams.

Use your skills to make an impact

Required Qualifications

Bachelor's degree

Licensed Practical Nurse (LPN) or Licensed Registered Nurse (RN) without restriction in applicable state

Minimum 5 years of experience with Humana or other healthcare claims systems

Ability to do extensive research on a given topic

Microsoft Excel skills (including sorting / filtering data and utilizing pivot tables)

Proven ability to pull and analyze large data sets and effectively communicate a meaningful narrative with those findings

Proven ability to perform clinical reviews and review medical records

Ability to collaborate and create connections with outside Clinical areas

Excellent presentation and communication skills, both oral and written

Strong relationship building skills

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Preferred Qualifications

PowerBI and / or PL-SQL Experience

MRM (Medical Records Management) Experience

Knowledge of Behavior Health and / or Inpatient Healthcare

Additional Information

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

To ensure Home or Hybrid Home / Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home / Office employees must meet the following criteria :

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.

Satellite, cellular and microwave connection can be used only if approved by leadership.

Employees 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 employees 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.

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

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$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 : 01-11-2026

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. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https : / / www.humana.com / legal / accessibility-resources?source=Humana_Website.