Medicaid Reconciliation Professional II

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

The Medicaid Process Improvement Professional 2 is responsible for analyzing and evaluating the effectiveness of existing Medicaid business processes, with a focus on eligibility, enrollment, claims, and compliance workflows. This role develops sustainable, repeatable, and measurable improvements that align with Medicaid program requirements and regulatory standards.

Assignments are varied and often require interpretation of Medicaid-specific policies and data. The role demands independent judgment to determine the most appropriate course of action, particularly when addressing operational inefficiencies, system discrepancies, or member-level variances. The professional collaborates closely with cross-functional teams, including state agencies, managed care organizations, and internal stakeholders, to drive process enhancements that improve member outcomes and operational accuracy.

The Medicaid Reconciliation Professional II supports process improvement initiatives by analyzing and enhancing Medicaid-related financial and operational workflows. This role involves researching best practices within and outside the organization to establish benchmarks and improve reconciliation accuracy, timeliness, and compliance. The ideal candidate should possess strong attention to detail with the ability to identify and resolve discrepancies and the ability to interpret and apply Medicaid policies and procedures.

Key responsibilities include :

Data Collection & Analysis : Gather and evaluate Medicaid eligibility data to identify discrepancies and opportunities for process optimization and state submissions

Process Enhancement : Collaborate with the Senior Professional and Leads and recommend and implement business practices that improve reconciliation efficiency, reduce errors, and support regulatory compliance

Technology Integration : Assess how new systems and tools can streamline Medicaid reconciliation processes and support automation efforts

Share feedback with the Senior Business Systems analysis associate for appropriate fix implementation

Strategic Alignment : Understand departmental and organizational goals, ensuring reconciliation processes align with broader Medicaid and healthcare compliance strategies

Decision-Making : Exercise independent judgment in routine tasks and contribute to problem-solving in ambiguous situations with minimal supervision

Guideline Adherence : Follow established procedures while identifying areas for improvement and innovation

Key Performance Indicators (KPIs)

Reconciliation Accuracy Rate : Percentage of Medicaid claims and payments accurately reconciled without discrepancies

Timeliness of Reconciliation : Average time taken to complete reconciliation cycles within reporting deadlines.

Comply with established due dates

Error Reduction Rate : Year-over-year decrease in reconciliation errors or mismatches

Process Improvement Implementation : Number of process improvement initiatives successfully implemented and sustained

Compliance Rate : Adherence to Medicaid regulations and audit requirements

Use your skills to make an impact

Required Qualifications

Undergraduate degree

Minimum 3 years of experience in Medicaid reconciliation enrollment or healthcare claims auditing

Minimum 3 years of experience with process improvement initiatives or change management in a healthcare setting

Demonstrated experience with data analysis and reporting tools (e.g., Excel, Access, or similar)

Proficiency in Microsoft Office Suite, especially Excel (pivot tables, VLOOKUP, formulas)

Familiarity with Medicaid systems, claims platforms, and reconciliation tools

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

Preferred Qualifications

Experience with data visualization tools (e.g., Power BI, Tableau)

Familiarity with SQL or other data querying languages

Experience working in cross-functional teams to drive operational efficiency

Proven track record of identifying and implementing process enhancements

Additional Information

As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called HireVue. HireVue Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.

If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and / or Video interview. 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

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.

$65,000 - $88,600 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 : 11-21-2025

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. 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