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Senior Claims Research & Resolution Professional (Florida Me

at Humana in Rogers, Arkansas, United States

Job Description

Description

The Senior Claims Research & Resolution Professional manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claims issues/complaints within contractual requirement both for and against the organization. The Senior Claims Research & Resolution Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

Description

The Senior Claims Research & Resolution Professional manages claims operations that involve customer contact, investigation, and settlement of claims for and against the organization. Approves all claims issues/complaints within contractual requirement both for and against the organization. The Senior Claims Research & Resolution Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Claims Research & Resolution Professional works with State Regulatory Agencies, providers, members, and external associations in the resolution of claims and provider operational issues/complaints. This position will trend identified issues, lead provider operational improvement initiatives, and will manage complex issues through resolution independently. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments. This position will work in a matrixed fashion with internal teams across the organization to facilitate timely resolution to provider operational issues, and will develop and maintain a positive relationship with the provider community. Functions could include but not be limited to documentation of billing guidance or assistance for providers, reviews of system edits for assurances of Florida Medicaid regulation alignment, and facilitation of provider trainings/educational sessions.

Required Qualifications

+ Bachelor’s degree or 5+ years working with Provider and claims data/equivalent experience

+ Humana Claims systems knowledge and/or experience (CAS)

+ Intermediate Microsoft Word, Excel, and Access Database and/or SQL skills

+ Experience and understanding in reading Florida Medicaid regulations

+ Certified Coder/Billing Experience

+ Experience in root cause analysis and issue resolution through cross-functional collaboration

+ Strong communication, critical thinking, problem resolution and interpersonal skills

+ 3+ years of Managed Care Experience, Medicaid and Medicare primarily

+ Work At Home requirements: Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10×1 (10mbs download x 1mbs upload) is required. A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

+ COVID Vaccination : We will require full COVID vaccination for this job as we are a healthcare company committed to putting health and safety first for our members, patients, associates and the communities we serve. If progressed to offer, you will be required to provide proof of full vaccination or documentation for a medical or religious exemption consideration where allowed by law. Requests for these exemptions should be submitted at least 2 week prior to your scheduled first day of work.

Preferred Qualifications

+ Experienced in communicating with providers to address operational issues

+ Florida Medicaid Managed Care Experience/knowledge

+ Knowledge of cross-functional teams across Humana

Additional information

+ Schedule: Monday to Friday from 8 am to 5 pm.

+ Training: Remotely

+ Work Location (Address): Work at Home Nationwide

+ % Travel: Minimal

Scheduled Weekly Hours

40

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Job Posting: JC195781356

Posted On: Oct 24, 2021

Updated On: Nov 05, 2021