Claims Research amp Resolution Professional

Profile

Description

The Claims Research & Resolution Professional 2 works with enterprise shares team comprised of calls/claims/contracting and external provider associates researching the resolution to a pending inquiry. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures. The individual in this role must exercise independent judgement and work under minimal supervision.

Responsibilities

Humana Gold Plus Medicare and Medicaid Plan (MMP) in IL, is seeking a Claims Research & Resolution Professional 2 claims educator, who will be responsible for carrying out Humana's proactive approach to minimize claims denials through claims education and training. This involves training providers on claims denials or underpayments, common claims errors, and Humana's claims tools, as well as working with internal teams to monitor providers post-training to ensure the issues causing the denials are resolved. The Claims Research & Resolution Professional 2 will conduct claims review that involve provider contact, investigation, and settlement of claims for and against the organization. Partners with claims operations to ensure prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims. Understanding of shared services claims organizational strategy and operating objectives, including their linkages to related areas, such as Provider Payment Integrity, Special Projects, Fee Schedule, and Contract Loading, etc., that supports the IL Market LTSS claims. Work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Required Qualifications

Minimum 3 years working knowledge of claims systems and billing requirements, examples of systems such as Claims Administration, Fee Schedule Management, etc.

Experience working with IL MMP Medicaid/Long Term Support Services, (LTSS), waiver claims.

Process-focused, with ability to leverage and enhance existing processes.

Proficiency in analyzing, understanding, and communicating complex issues.

Thorough understanding of managed care contracts, including contract language and reimbursement

Exceptional time management and ability to manage multiple priorities in a fast-paced environment.

Intermediate to Advanced working knowledge using MS Word, Excel, and Powerpoint.

Additional Requirement / Adherence

Workstyle: Combination remote work at home with occasional field base visits to market and provider offices

Preferred Location: Illinois (Schaumburg, Chicago)

Alternate Locations: Kentucky, Florida, Wisconsin

Schedule: Monday - Friday 8:00 AM t0 5:00 PM Eastern

Travel: Leader will discuss at interview

10-15% within Illinois territory.

Work at Home Guidance

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

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

Humana Driver's Safety Program

This role is part of Humana's Driver safety program and therefore requires an individual to have a valid state driver's license and proof of personal vehicle liability insurance with at least 100/300/100 limits.

Preferred Qualifications

Bachelor's Degree in Business, Public Health or related field.

Knowledge of Humana's internal policies, procedures and systems.

Experience with CRM.

Experience working with providers is strongly desired.

Experience with provider systems and contract language understanding

Experience with claims systems, submission processes, coding, and/or dispute resolution

Additional Information

Covid Policy

Humana and its subsidiaries require vaccinated associates who work outside of their home to submit proof of vaccination, including COVID-19 boosters. Associates who remain unvaccinated must either undergo weekly negative COVID testing OR wear a mask at all times while in a Humana facility or while working in the field.

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by Montage/Modern Hire, a third-party vendor. This technology provides our team of recruiters and hiring managers an enhanced method for decision-making.

If you are selected to move forward from your application prescreen, you will receive correspondence inviting you to participate in a pre-recorded Voice Interview and/or an SMS Text Messaging interview. If participating in a pre-recorded interview, you will respond to a set of interview questions via your phone. You should anticipate this interview to take approximately 10-15 minutes.

If participating in a SMS Text interview, you will be asked a series of questions to which you will be using your cell phone to answer the questions provided. Expect this type of interview to last anywhere from 5-10 minutes. Your recorded interview(s) via text and/or pre-recorded voice will be reviewed and you will subsequently be informed if you will be moving forward to next round of interviews.

#L1-Hybrid

Scheduled Weekly Hours

40

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.

Company info

Humana Inc.
Website : http://www.humana.com