Claims Research and Resolution Professional 2

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