Greater opportunities to build the life you want
Greater Peoria, IL
Greater Peoria, IL

Provider Reconciliation Program Lead



Posted on Saturday, June 22, 2024

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

Humana is a $77 billion (Fortune 41) market leader in integrated healthcare with a clearly defined purpose to help people achieve lifelong well-being. As a company focused on the health and well-being of the people we serve, Humana is committed to advancing the employment experience and vitality of the associate community. Through offerings anchored in a whole-person view of human well-being, Humana embraces a focus on stimulating positive individual and population changes while nurturing a sense of security, enabling people to live life fully and be their most productive.

Against that backdrop, we are seeking an experienced healthcare leader to join our team as the Provider Reconciliation Program (PRP) Lead within the Healthcare Quality Reporting and Improvement (HQRI) organization. HQRI (comprised of Risk Adjustment and Health Quality & Stars) is responsible for improving health outcomes and advancing the care experience of our members and provider partners. The Risk Adjustment team collects and submits members’ health information to CMS for the purpose of accurately reporting the members health status, as well as inclusion in the appropriate clinical programs. The Health Quality and Stars team centralizes quality improvement and governance processes targeting Humana’s Medicare Advantage members while also managing compliant data submissions to CMS in adherence with the Stars Rating Program.

The Provider Reconciliation Program (PRP) Lead promotes and improves the quality and measurement of care delivery programs within markets while working on problems of diverse scope and complexity ranging from moderate to substantial.

The Provider Reconciliation Program (PRP) Lead works closely with technology, Stars and regional areas to support the program goals and strategies.

The Provider Reconciliation Program (PRP) Lead engages and partners with physicians, physician groups, and regional leadership to drive initiatives. Influences and consults on matters related to quality and measurement of care delivery programs with a market(s), exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision using independent judgment on analysis of variable factors determining the best course of action.

  • Lead and develop a team of senior professionals
  • Manage provider inventory for the program to support HQRI strategies and sustainable program growth
  • Lead through substantial program changes including automation of program processes
  • Execute effective communications and strategies streamlining the information received by each region
  • Develop, maintain and strengthen relationships with both multiple areas across corporate and regional areas
  • Analyze divisional/regional data and employ improvement strategy utilizing partnerships with both Corporate and regional business areas
  • Develop a working knowledge of the company, its products, the healthcare industry and the regulatory agencies that govern us in order to develop messaging through effective communication channels

Use your skills to make an impact

Required Qualifications

  • 2+ years leadership experience
  • 3+ years RA experience, either Corporate or regional
  • Claims processing experience/knowledge
  • Experience collaborating with legal, risk management, internal audit and compliance partners
  • Strong knowledge of Microsoft products
  • Excellent written and verbal communications skills
  • Proficiency in data analysis
  • Demonstrated process improvement experience
  • Ability to work/interact with all levels, including senior leadership, external partners and provider offices
  • Highly motivated, accountable and works with minimal direct supervision

Preferred Qualifications

  • Stars experience/knowledge
  • SQL experience/knowledge
  • Project management
  • Power BI experience
  • AAPC or AHIMA coding certification
  • EMR experience
  • Quality assurance experience
  • Degree in Healthcare Management, Healthcare Administration or related program
  • Experience working with external partner including providers and EMR vendors

Scheduled Weekly Hours


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.

$93,000 - $128,000 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.

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 because he or she is a protected veteran. It is also the policy of Humana to take affirmative action to employ and to advance in employment, all persons regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, 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.