Claims Research amp Resolution Professional - Remote LA

Profile

Description

The Claims Research & Resolution Professional 2 manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claim settlements both for and against the organization. The Claims Research & Resolution Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Claims Resolution Professional Role Overview


Monitors claims administration areas to identify and minimize the impact of irregularities in claims processing.
Identifies claims payment issues and responding to escalation.
Utilizes root-cause analysis to identify claims issues; manage the development and implementation of process improvement projects.
Works closely with the Program Integrity Officer, Claims Cost Management and Claims Processing Organization to develop and implement processes for cost avoidance, minimization of claims overpayments and need for recoupments, coordination of resources, coordination of benefits, and payment recoupment.


Required Qualifications


Must reside in the state of Louisiana and be willing to travel locally for meetings
Minimum (2) years of claims management experience in the healthcare industry.
Experience in claims operation preferably in Medicaid.
Familiarity with medical terminology and ICD-9/ICD-10, CPT, HCPCS
Comprehensive knowledge of Microsoft Office tools such as Word, Excel and PowerPoint.
Thorough understanding of claims adjudication processes.
Proven analytical skills .
Proven ability to develop working relationships within a highly matrixed business environment.
Excellent communication skills, both oral and written
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.
Must be available to work Monday - Friday and require some travel for meetings


Work-At-Home Requirements


Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.
A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.
Satellite and Wireless Internet service is NOT allowed for this role.


Preferred Qualifications


Associate Degree.
Experience working with internal claims systems.


Additional Information

Interview Format

As part of our hiring process, we will be using an exciting interviewing technology provided by 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 or computer 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.

Section 1121 of the Louisiana Code of Governmental Ethics states that current or former agency heads or elected officials, board or commission members or public employees of the Louisiana Health Department (LDH) who work directly with LDH's Medicaid Division cannot be considered for this opportunity. A separation of two (2) or more years from LDH is required for consideration. For more information please visit: Louisiana Board of Ethics (la.gov) (****opinion)

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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 ****

Company info

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