Director, Claims Processing - Humana Inc. (NYSE: HUM) - Louisville, KY
(2007-04 - 2025-05)
Directed $75M operations budget across multiple medical lines of business. Managed 7 direct-report managers and over 1,300 associates (649 onshore, 700 offshore) across several domestic and international locations.
- Oversaw claims operations for Medicare, Medicaid, and Group accounts; ensured compliance with CMS and state requirements.
- Routinely attended C-level executive team meetings and provided pertinent updates on claims quality metrics, cycle times for Medicare and Medicaid, and various projects.
- Improved corrected claim auto-adjudication from 10% to 55%, significantly reducing manual workload and improving turnaround times.
- Led successful implementations for all new Medicaid states and Group Medicare integration.
- Ensured payment integrity through testing and analyzing rule data prior to vendor and platform implementation.
- Analyzing disputes data to determine impact to provider and claims operations in accordance with payment integrity activities.
- Participated in discussions to determine prepay and post-pay rules and predict outcomes of the implementation on Humana's claims platform to ensure payment integrity.
- Successfully led migration from legacy claims system to current claims adjudication system.
- AI RFP: Led process to implement an AI solution to improve auto adjudication rate.
- American Eldercare Integration: Onboarded Long-Term Care business into Humana.
- Humana Military Crisis Response: Rescued underperforming vendor operations that risked a major government contract.
- Aetna Merger Integration: Oversaw claims workstream planning for potential acquisition.
- Vendor Transitions: Led outsourcing of Commercial and Medicare claims.
Enrollment Manager, Medicare and PDP - Humana Inc. (NYSE: HUM) - Louisville, KY
(2005-03 - 2007-04)
- Led enrollment processing for Medicare Advantage and PDP members.
- Developed workflow system to monitor inventory and improve processing times.
- Partnered with Finance to build staffing models based on productivity, lost time, and volume.
- Collaborated with the Quality team to build a robust quality monitoring program that identified operational inefficiencies and guided team-level improvements.
Various Progressing Roles - Humana Inc. (NYSE: HUM) - Louisville, KY
(1989-04 - 2005-03)
Held various roles with increasing responsibility across the Claims organization.
- As part of the Special Investigations Unit, reviewed provider and member claims for possible fraud and collected information for leaders for possible prosecution and recoupment of funds taken by illegally using Humana's claims system.
- Created and implemented key claims policies and processes for Commercial and Medicare Claims with ultimate Claims Manager responsibility of the Kentucky market.
