Company name
Humana Inc.
Location
Springfield, OH, United States
Employment Type
Full-Time
Posted on
Dec 28, 2022
Profile
Description
The Claims Educator is responsible for ensuring prompt and accurate provider claims processing of original claims, resubmissions, and overall adjudication of claims. The Claims Educator manages claims operations that involve member contact, investigation, and settlement of claims for and against the organization. The overall Claims Resolution & Education team is responsible for carrying out Humana's proactive approach to minimize claims denials through education and training. This involves training providers on claims denials or underpayments, common claims errors, and Humana's claims tools, as well as working with internal teams to monitor providers post-training to ensure the issues causing the denials are resolved. Work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.
Responsibilities
Key Role Objectives
Conduct training with providers on claims denials or underpayments related to provider complaints, common claims errors, and Humana's claims tools
Collaborate with Provider Relations Representatives and internal teams to conduct targeted training for providers and their staff to address high rates of claim denials or patterns of denied claims identified via root cause analysis
Monitor providers post-training to ensure the issues causing the denials are resolved
Assist in development and implementation of processes for cost avoidance and claims processing systems capable of paying claims in accordance with state and federal requirements
Collaborate with Provider Relations Representatives to optimize provider experience and satisfaction
Partner with Provider Relations Representatives to ensure prompt resolution of provider inquiries, concerns, or problems associated with claims payment
Develop and implement claims processing systems capable of paying claims in accordance with state and federal requirements
Develop processes for cost avoidance
Ensure minimization of claims recoupments
Work with internal corporate partners to ensure cross-department communication and resolution of provider's issues
Work with internal resources and systems (e.g., claims adjudication system) to provide the Perfect Experience in all provider interactions with Humana's South Carolina Medicaid plan related to claims
Ensure compliance with South Carolina's Managed Care Contractual requirements for provider relations, such as claims dispute resolution within specified timeframes
Required Qualifications
Bachelor's degree
Less than 5 years of technical experience
Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Experience working with or in health care administration setting
Exceptional relationship management skills
Understanding of health insurance claims and ability to analyze data to resolve provider service issues
Excellent written and verbal communication skills
Proficiency in analyzing, understanding, and communicating complex issues
Thorough understanding of managed care contracts, including contract language and reimbursement
Exceptional time management and ability to manage multiple priorities in a fast-paced environment
Knowledge of Microsoft Office applications
Must be passionate about contributing to an organization focused on continuously improving provider experiences
Preferred Qualifications
Experience with South Carolina Medicaid
Experience with claims systems, adjudication, submission processes, coding, and/or dispute resolution
Contract negotiation and implementation experience
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 https://www.humana.com/legal/accessibility-resources?source=Humana_Website.
Company info
Humana Inc.
Website : http://www.humana.com