Senior Claims Research amp Resolution Professional - FL Medicaid

Profile

Description

The Senior Claims Research & Resolution Professional manages claims operations for Florida Medicaid line of business which may involve customer contact, investigation, and settlement of claims 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. Reviews complex issues which may create claim settlements both for and against the organization.

Responsibilities

The Senior Claims Research & Resolution Professional works within the Florida Medicaid Operations team with focused work to solve claims issues with insurance companies, providers, members, and collection services in the settlement of claims. A ssists with provider audits, provider network Service Level Agreements and Florida Medicaid contractual requirements as needed by department. Partners with internal department counterpart to assist with managing the Florida Medicaid Physician Incentive Program. Researches and finds resolutions to complex claims payment issues through trend analysis of denials and provider complaints using dashboard data, or individually pulled data. Performs high level claims root cause analysis. Makes decisions on moderately complex to complex issues regarding resolutions for provider loads and claims issue resolution, and work is performed without direction. Responsible for creating and managing education material and updating as dictated by program or contract changes. Works closely with various corporate departments where their involvement is crucial to the success of projects. Exercises considerable latitude in determining objectives and approaches to assignments. Begins to influence department's strategy.

Trend analysis and claims research based on Dashboard data results

Effectively communicates findings to management for appropriate escalation

Creates and updates provider FAQ's for online posting

Collaborates routinely with multiple levels of management and departments

Actively involved in AHCA initiatives and compliance adherence inquiries

Required Qualifications

Bachelor's degree

5 or more years of technical experience (Claims Processing, Claims Payment, Root Cause Analysis and Trends)

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Strong Attention to Detail

Strong Communication, Critical Thinking, Problem Resolution and Interpersonal Skills

Experience working with Provider Data

Intermediate Microsoft Word and Excel skills

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 of 10x1 (10mbs download x 1 mbs upload) is required.

A dedicated home office space, with a locked door, lacking ongoing interruptions to protect member PHI / HIPPA information

Work shift will be in Eastern Time Zone

Preferred Qualifications

Claims Research

Medical Claims Processing experience

Microsoft Access Database and/or SQL skills

Additional Information

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com