Plan Build Representative

Profile

Description

The Plan Build Representative 2 loads data from tables into multiple platforms which can include rates, CPT codes, etc. Implements provider demographic updates to remain compliant. Testing and implementation of new platform migration.

Responsibilities

Analyzes and maintains required changes for existing health plans driven by market product design, legislative and regulatory needs

Determines required system changes to support new products, services, or efficiencies through design, test, and implementation stages

Daily review of claim pending reports to correct Computer Science Cooperation/CarePlus Health Plans' Internal (CSC) system issues for benefit and provider loads

Internal audit of claims in Health Rules Payer (HRP) system to ensure each claim processes with expected benefit, provider and fee table and contract configuration results

Internal audit of claims, authorizations and processes connected to the Provider Portal to ensure authorization requests, claims data and portal processes (secure messaging) respond with expected results

Working of error reports to ensure provider data integrity

Ensures adherence of compliance and audit processes, and supports system error resolution and remediation

Supports training and development of procedures

Required Qualifications

Proficient in Microsoft Word, Excel and PowerPoint

1 or more years of experience working in a healthcare setting

Overall knowledge of Medicare standards and regulations

Preferred Qualifications

Associates Degree (AA/AS) and/or equivalent

Experience working with Microsoft Access and/or PowerBI

Experience in Health Maintenance Organization (HMO) claims processing

Knowledge of medical terminology, ICD-10 and CPT/HCPC coding

Provider relations and/or provider services experience

Contract and/or provider loading experience

Experience readying provider contracts

Additional Information

Schedule: Monday- Friday 8AM-5PM EST

Modern Hire: 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.

Work-At-Home Requirements

WAH 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.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA 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.

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

#LI-BB1

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