Humana/iCare is seeking a Claims Research and Resolution Representative 4 to join our growing team. The Claims Research & Resolution Representative 4 is responsible for assisting the Supervisor of Claims Research & Resolution in providing general support and expertise to the claims and appeals team. Join this dedicated team and lead change in how health care for the underserved in Wisconsin is managed.
Responsibilities
Essential Duties and Responsibilities:
- Promptly and accurately address resolution of provider claims issues.
- Assist the Supervisor of Claims Research & Resolution in providing general support and expertise to the Operations team, including guidance and expertise in reviewing, researching, and responding to claims processing issues to providers in a timely manner.
- Coordinate work assignments for claims analysts to ensure that all work is completed in a timely fashion and monitor, track, and direct day to day operations of claims staff.
- Assume accountability for ensuring individuals/team meet their performance metric goals and assist staff in handling complicated or unusual claims and provider issues.
- Monitor daily inventory reports to assess if assignment changes are needed; trend inventory levels and communicate with claims processing vendor to ensure levels remain at an acceptable level.
- Attend weekly and ad hoc meetings with iCare’s claims processing vendor to assign priorities, determine resolution, and develop processes affecting iCare Operations.
- Compile results of inquiry research to determine the root cause of provider issues.
- Exercise proper judgment on questionable claims.
- Assist with the handling/resolution of provider appeals and operation related encounter errors according to iCare policy/procedures.
- Investigate trends, surface issues, identify root problems, and collaboratively work with various iCare teams/individuals to resolve Operational related issues.
- Monitor and work ICH Call Tracking queue and respond to all Department Claims emails.
- Ensure high dollar claims are handled accurately and timely.
- Approve Claims Payment Cycles and serve as backup for submitting Medical Reviews to 3rd party reviewer.
Required Qualifications
- Three (3) or more years of claims experience in an HMO or health insurance environment.
- Medicare and Medicaid experience.
- Experience analyzing all facets of complex claim situations and determining root cause of the issue.
- Proficiency with Microsoft Office applications such as Access, Excel, Word, and Outlook.
- Working knowledge of medical terminology, CPT procedure coding, ICD-9 and ICD-10 diagnosis codes, RUGS and DRG knowledge.
Preferred Qualifications
- Strong technical background with advanced proficiency in Excel.
- Leadership or coaching/training experience.
Additional Information
- Workstyle: Home. Home workstyle is defined as remote but will use Humana office space on an as needed basis for collaboration and other face-to-face needs.
- Typical Work Days/Hours: Monday – Friday, 8:30am – 5:00pm Central Standard Time (CST)
WAH Internet
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
- At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested.
- Satellite, cellular and microwave connection can be used only if approved by leadership.
- Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Modern Hire
As part of our hiring process for this opportunity, we will be using an interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.
SSN Alert
Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from [email protected] with instructions on how to add the information into your official application on Humana’s secure website.
Nationwide Remote – This is a remote nationwide position.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$40,200 – $55,200 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.