Claims Research & Resolution Representative

at Humana in Boise, Idaho, United States

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

Humana/iCare is seeking a Claims Research and Resolution Representative 3 to join our growing team. The Claims Research & Resolution Representative 3 is responsible for researching, examining and responding to claims processing issues in a timely manner, including provider claims projects, complicated and unusual claims. This position provides input and makes recommendations for solutions to departmental and interdepartmental issues and is responsible for researching and resolving member billing concerns. Join this dedicated team and lead change in how health care for the underserved in Wisconsin is managed.

+ Coordinate exchange of provider information with appropriate iCare vendors (claims, pharmacy, subrogation and cost saving).

+ Respond in a timely fashion to provider questions and issues regarding claims payment, in the form of reconsiderations, formal appeals and member bills.

+ Interface with iCare/Cognizant personnel to establish and document claims processing, pricing and network policies and procedures.

+ Provide prompt, courteous and excellent service to internal and external customers.

+ Research and examine problem claims to determine the cause of the claim's problem status. Escalate trends and educational opportunities to the appropriate contacts.

+ Handle complicated or unusual claims and resolves provider issues.

+ Exercise proper judgement on questionable claims (i.e. timely filing and high dollar exceptions).

+ Understand the complexity of the enrollment, benefit and authorization process as it relates to claims.

+ Assist with the documentation of interdepartmental procedures.

+ Participate in claims-related audits initiated by the State, CMS or outside vendors.

+ Maintain proficiency in all department queues (authorization, member bill, review/reopening, LTC).

+ Assist Lead Claims Analyst as needed (department emails, special projects, Macess documents).

+ Review and route Macess documents.

+ Work Cognizant emails regarding enrollment questions.

+ Work ICH Call Tracking's.

+ Work high dollar claims for Medicaid.

Use your skills to make an impact

Required Qualifications

+ Two (2) years of claims experience in an HMO or health insurance environment.

+ Experience analyzing all facets of complex claim situations and determining root cause of the issue.

+ Experience with Medicaid and Medicare.

+ Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.

+ Working knowledge of medical terminology, CPT-4 procedures, ICD-9 diagnosis codes, and DRG experience.

Preferred Qualifications

+ Experience as a customer service or provider services representative.

Additional Information

+ Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.

+ Typical Work Days/Hours: Monday - Friday, 8:30am - 5:00pm Central Standard Time (CST)

Nationwide Remote - This is a remote nationwide position.

WAH Internet Requirements

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees 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.

+ Employees 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 employees 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.

Benefits

Humana offers a variety of benefits to promote the best health and well-being of our employees and their families. We design competitive and flexible packages to give our employees a sense of financial security-both today and in the future, including:

+ Health benefits effective day 1

+ Paid time off, holidays, volunteer time and jury duty pay

+ Recognition pay

+ 401(k) retirement savings plan with employer match

+ Tuition assistance

+ Scholarships for eligible dependents

+ Parental and caregiver leave

+ Employee charity matching program

+ Network Resource Groups (NRGs)

+ Career development opportunities

HireVue

As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

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 decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$37,200 - $51,200 per yearThis 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.

Humana complies with all applicable federal civil rights laws and does not discrim