Senior Medical Risk Advisor - Health Claims Management (Hiring Immediately)

Company: USAA
Location: Phoenix
Posted on: May 28, 2025

Job Description:

Why USAA?
At USAA, our mission is to empower our members to achieve financial security through highly competitive products, exceptional service and trusted advice. We seek to be the #1 choice for the military community and their families.

Embrace a fulfilling career at USAA, where our core values - honesty, integrity, loyalty and service - define how we treat each other and our members. Be part of what truly makes us special and impactful.

The Opportunity
USAA Life Company's Claim Team is seeking a talented Medical Specialist Principal to play a crucial role in advising the Medicare Supplement Claims Department on the morbidity and claims risk of health policies, including Medicare Supplement contracts and claims. The responsibilities will include providing support to investigators related to Medical Procedures and CPT coding issues and fraud waste and abuse activity. - You will participant in settlement negotiations when they've provided assistance in performing medical and coding reviews.

Your responsibilities will include reviewing complicated medical histories, assessing medical testing results, and ensuring claims payment accuracy in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines. Additional responsibilities include: - Regularly reviewing USAA Life Company's actual morbidity and claims experience to safeguard long-term morbidity outcomes; providing expert medical consultation on Medicare Supplement policies and claims; - conducting research on medical advancements and public health trends, including trends involving fraud, waste, and abuse, to ensure that risk assessment strategies are current and effective.

We offer a flexible work environment that requires an individual to be in the office 4 days per week. This position can be based in one of the following locations: San Antonio, TX, Phoenix, AZ, Colorado Springs, CO, Tampa, FL, or Plano, TX, . Relocation assistance is not available for this position.

What you'll do:
Interprets relevant medical literature for application to appropriate health insurance underwriting policies and guidelines.

Applies advanced medical expertise by serving as primary resource for Health Claims for the approach to medical risk assessment rules.

Guides and trains claim and special investigation unit investigators and aids in the continued advancement of their medical risk acumen.

Serves as the primary point of contact within Claims and Fraud for medical trends research and impact assessment of fraud waste and abuse.

Advises claims and SIU investigators on the proper risk assessment of fraud waste and abuse claims, with particular focus on complex medical impairments and sophisticated fraud schemes.

Provides expert medical research and input to help drive sound claim and fraud guidelines.

Participates in special project work, particularly involving the automated review of digital health data.

Reviews and interprets relevant medical literature for application to health claims policies and guidelines.

Collaborates with senior leaders and staff to establish claims and fraud waste and abuse philosophy, guidelines, and procedures.

Applies expert knowledge of fraud risk associated with health claims.

Ensures risks associated with business activities are effectively identified, measured, monitored, and controlled in accordance with risk and compliance policies and procedures.

What you have:
Bachelor's degree OR 4 years of related experience (in addition to the minimum years of experience required) may be substituted in lieu of degree . (Total of 14 years of experience without bachelor's degree)

10 years of progressive health fraud experience, to include 6 years of experience working as a Registered Nurse (RN), Nurse Practitioner (NP), or Medical Doctor (MD) with accountability for highly complex projects/initiatives with significant impact.

4 years of experience in medical coding and/or Medicare billing practices.

Ability to interpret electrocardiograms and stress test tracings.

Demonstrated strategy development and thought leadership within the medical field.

Leading edge knowledge and expertise in theories, techniques and/or technologies within the medical field.

Experience applying subject-matter expertise to produce innovative solutions for work deliverables.

Experience collaborating with key resources and stakeholders to achieve strategic goals required.

What sets you apart:
US military experience through military service or a military spouse/domestic partner

Medicare Claims Expertise: -Minimum of 4 years working with Medicare Supplement claims and/or Medicare-related claims.

Expert Advice: -Ability to review complicated medical records and medical claims, and provide expert advice . - Conducts review of complex healthcare fraud investigations and providing claims support

Medical Coding Proficiency: -At least 4 years of experience and proficiency in medical coding. - - - Exercises knowledge of CPT coding, IC-9, ICD-10, HCPC and continues learning of new coding guidelines.

Provides guidance and assistance to all investigators and claims with regards to coding issues and investigations with deep understanding and experience with various indicators of fraud, waste, and abuse.

Regulatory Experience: -Experience working with Medicare state and federal regulations.

Investigation Skills: -Ability to conduct complex healthcare fraud investigation reviews.

Knowledge of health insurance claims operations, particularly Medicare Supplement claims handling (e.g., claims, enrollment, underwriting).

Knowledge of processes, procedures, and requirements related to the Centers for Medicare & Medicaid Services (CMS).

Ability to be deposed during litigation involving special investigation cases.

Exceptional ability to summarize, review, and analyze medical records to determine the accuracy of documentation submitted.

Compensation range: The salary range for this position is: $164,780 - $314,960

Compensation: USAA has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location.

Employees may be eligible for pay incentives based on overall corporate and individual performance and at the discretion of the USAA Board of Directors.

The above description reflects the details considered necessary to describe the principal functions of the job and should not be construed as a detailed description of all the work requirements that may be performed in the job.

Benefits: At USAA our employees enjoy best-in-class benefits to support their physical, financial, and emotional wellness. These benefits include comprehensive medical, dental and vision plans, 401(k), pension, life insurance, parental benefits, adoption assistance, paid time off program with paid holidays plus 16 paid volunteer hours, and various wellness programs. Additionally, our career path planning and continuing education assists employees with their professional goals.

For more details on our outstanding benefits, visit our benefits page on USAAjobs.com.

Applications for this position are accepted on an ongoing basis, this posting will remain open until the position is filled. Thus, interested candidates are encouraged to apply the same day they view this posting.

USAA is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Keywords: USAA, Prescott , Senior Medical Risk Advisor - Health Claims Management (Hiring Immediately), Executive , Phoenix, Arizona