Become a part of our caring community and help us put health firstHumana Healthy Horizons in Indiana is seeking a Senior Claims Research & Resolution Professional who is dedicated to reviewing provider claims ensuring prompt and accurate provider claims processing according to State reimbursement guidelines by applying guidance, and making appropriate decisions which may include interpretation of provider information or data. The claims review professional works in collaboration with the chief information officer (CIO) to ensure timely and accurate submission of encounter data and works with special investigation unit (SIU) on matters that require SIU review or investigation.The Senior Claims Research & Resolution Professional exercises independent judgment and decision making on complex issues regarding job duties and related tasks, uses independent judgment requiring analysis of variable factors to determine the best course of action, and ensures compliance with Indiana's Managed Care contractual requirements for claims dispute resolution within specified timeframes.The Senior Claims Research & Resolution Professional Key Responsibilities:
Acts as a thought-leader and collaborates with Corp Shared Services and other leaders to ensure prompt and accurate provider claims processing.
Serve as the market point of contact and liaison with Technology teams to ensure accurate and timely encounter submissions.
Works with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported appropriately.
Partners with the Provider Education and Outreach team to identify targeted training for Home-and-Community Based (HCBS)/Long Term Service Support (LTSS) providers.
Responsible for annual and quarterly State reporting of grievance and appeals.
Workstyle: Hybrid Office, required to work at the Humana Healthy Horizons office in downtown Indianapolis, or within 10 miles from the mile square of downtown Indianapolis, at least three days per week to coordinate with the State office.
Use your skills to make an impactRequired Qualifications
Must reside in the state of Indiana, be able to travel in the state of Indiana, and work in the Indianapolis office at least three days per week.
3+ years of medical claims review experience.
Advanced knowledge of Medicaid and Medicare claims processes.
Demonstrated leadership experience.
Ability to collaborate with shared services and interact with all levels of leadership.
Proven problem solving and critical thinking skills.
Excellent written and verbal communication skills.
Knowledge of how business processes relate to data.
Ability to analyze large data files to ensure claims are paying accurately before being released.
Intermediate to Advanced knowledge of Microsoft Word, Excel, and Access.
This role is a 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 100,000/300,000/100,000 limits.
This role is considered patient facing and is a part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.
Work at Home Requirements
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.
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
Bachelor's degree.
Experience working with HCBS, LTSS, Physical Health (PH), and Behavioral Health (BH) providers.
Advanced proficiency working with healthcare data, specifically medical claims.
Advanced proficiency with Excel (ability to create pivot tables and put it into consumable information).
Experience using the following system: MHK, Availity, or APEX.
Additional Information:
Workstyle: Hybrid Office, required to work at the Humana Healthy Horizons office in downtown Indianapolis, or within 10 miles from the mile square of downtown Indianapolis, at least three days per week to coordinate with the State office.
Travel: Up to 15% travel in the state of Indiana to provider offices and Humana locations.
Core Workdays & Hours: Typically, Monday - Friday; 8:00am - 5:00pm Eastern Standard Time (EST).
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
Interview FormatAs part of our hiring process, we will be using an exciting interviewing technology provided by Hire Vue, 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.Scheduled Weekly Hours40About usHumana 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 EmployerIt 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 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=HumanaWebsite.
