Claims Research and Resolution Representative

Claims Research and Resolution Representative

locations

• Remote Wisconsin
• Work at Home – Utah
• Work at Home – Washington
• Work at Home – Virginia
• Work at Home – Texas
• Work at Home – Tennessee
• Work at Home – South Carolina
• Work at Home – Pennsylvania
• Work at Home – Oregon
• Work at Home – West Virginia
• Work at Home – New York
• Work at Home – Ohio
• Work at Home – North Carolina
• Work at Home – New Mexico
• Work at Home – New Jersey
• Work at Home – New Hampshire
• Work at Home – Nevada
• Work at Home – Nebraska
• Work at Home – Missouri
• Work at Home – Massachusetts
• Work at Home – Montana
• Work at Home – Mississippi
• Work at Home – Minnesota
• Work at Home – Louisiana
• Work at Home – Michigan
• Work at Home – Kentucky
• Work at Home – Maryland
• Work at Home – Kansas
• Work at Home – Iowa
• Work at Home – Indiana
• Work at Home – Illinois
• Work at Home – Idaho
• Work at Home – Georgia
• Work at Home – Florida
• Work at Home – Colorado
• Work at Home – California
• Work at Home – Arizona
• Work at Home – Arkansas
• Work at Home – Alabama
• Work at Home – Oklahoma
• Work at Home – Wyoming
• Work at Home – Vermont
• Work at Home – Rhode Island
• Work at Home – North Dakota
• Work at Home – Maine
• Work at Home – Delaware
• Work at Home – Connecticut
• Work at Home – South Dakota

time type

Full time

job requisition id

R-297975

Description

Humana/iCare is seeking a Claims Research and Resolution Representative 4 to join our growing team. The Claims Research & Resolution Representative 4 is responsible for assisting the Supervisor of Claims Research & Resolution in providing general support and expertise to the claims and appeals team. Join this dedicated team and lead change in how health care for the underserved in Wisconsin is managed.

Responsibilities

Essential Duties and Responsibilities:

• Promptly and accurately address resolution of provider claims issues.
• Assist the Supervisor of Claims Research & Resolution in providing general support and expertise to the Operations team, including guidance and expertise in reviewing, researching, and responding to claims processing issues to providers in a timely manner.
• Coordinate work assignments for claims analysts to ensure that all work is completed in a timely fashion.
• Monitor the due dates for completion of all assignments made to the claims team to ensure the highest level of customer service to the provider community.
• Assume accountability for ensuring individuals/team meet their performance metric goals.
• Monitor, track and direct day to day operations of claims staff.
• Monitor daily inventory reports in order to assess if assignment changes are needed; trend inventory levels and communicate with claims processing vendor to ensure levels remain at an acceptable level.
• Attend weekly and ad hoc meetings with iCare’s claims processing vendor to assign priorities, determine resolution, and develop processes affecting iCare Operations.
• Compile results of inquiry research to determine the root cause of provider issues.
• Assist staff in handling complicated or unusual claims and provider issues.
• Exercise proper judgment on questionable claims.
• Assist with the handling/resolution of provider appeals and operation related encounter errors according to iCare policy/procedures.
• Investigate trends, surface issues, identify root problems, and collaboratively work with various iCare teams/individuals to resolve Operational related issues.
• Understand the enrollment process as it relates to claims processing.
• Monitor and work ICH Call Tracking queue.
• Respond to all Department Claims emails.
• Ensure high dollar claims are handled accurately and timely.
• Provide back up for approving Claims Payment Cycles and submitting Medical Reviews to 3rd party reviewer.

Required Qualifications

• Three (3) or more years of claims experience in HMO or insurance environment.
• Medicare and Medicaid experience.
• Experience analyzing all facets of complex claim situations and determining root cause of the issue.
• Proficiency with Microsoft Office applications such as Access, Excel, Word, and Outlook.
• Analytical skills and detail-oriented ability.
• Working knowledge of medical terminology, CPT procedure coding, ICD-9 and ICD-10 diagnosis codes, RUGS and DRG knowledge.
• Ability to multi-task and professionally interact with multiple departments.
• 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.

Preferred Qualifications

• Strong technical background with advanced proficiency in Excel.
• Leadership or coaching/training experience.

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)
• Benefits: Benefits are effective on day 1. Full time Associates enjoy competitive pay and a comprehensive benefits package that includes: 401k, Medical, Dental, Vision and a variety of supplemental insurances, tuition assistance and much more!
• COVID-19 Vaccine Information: 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 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.

Social Security Alert

Humana Values personal identity protection. Please be aware that applicants selected for leader review may be asked to provide a social security number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions to add the information into the application at Humana’s secure website.

Scheduled Weekly Hours

40